Salforddiabetescare.co.uk

National Institute for
Clinical Excellence
NHS
National Institute for
Clinical Excellence
Management of
Clinical Guideline
type 2 diabetes
Renal disease - prevention and early management INHERITED
February 2002
Clinical Guideline F
Management of type 2 diabetes
Renal disease - prevention and early management
Issue date:
Review date:
Ordering Information
Copies of this guideline can be obtained from the NHS Response Line by telephoning 0870 1555 455 and
quoting ref. N0061. A patient version of this document, Screening for and early management of kidney
(renal) problems, can also be obtained by quoting ref. N0062 for an English version and N0063 for an
English/Welsh version.
This document has been circulated to the following:
• Health Authority Chief Executives in England and Wales
• NHS Trust Chief Executives in England and Wales • Medical and Nursing Directors in England and Wales • Consultant endocrinologists and diabetologists in England and Wales • Consultant nephrologists in England and Wales • Chief Executive of the NHS in England • Special Health Authority Chief Executives • Community Health Councils in England and Wales • Chief Medical, Nursing Officers and Pharmaceutical Officers in England and Wales • Medical Director & Head of NHS Quality - National Assembly for Wales • Clinical Effectiveness Support Unit - Wales • Representative bodies for health services, professional organisations and statutory bodies, Royal Colleges This guidance is written in the following context:
This guidance represents the view of the Institute, which was arrived at after careful consideration of the
available evidence. Health professionals are expected to take it fully into account when exercising their clinical
judgment. This guidance does not, however, override the individual responsibility of health professionals to
make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or
guardian or carer.
National Institute for
Clinical Excellence
ISBN: 1-84257-147-8Published by the National Institute for Clinical ExcellenceFebruary 2002 Copyright National Institute for Clinical Excellence February 2002. All rights reserved. This material may be freelyreproduced for educational and not for profit purposes within the NHS. No reproduction by or for commercial organisations ispermitted without the express written permission of the Institute.
Contents
Appendix A - Guideline Development Group and Recommendations PanelAppendix B - Guidelines Advisory CommitteeAppendix C - Patient information This guideline is a part of the Inherited Clinical Guidelines work programme. It was commissionedby the Department of Health before the Institute was formed in April 1999. It has followed closelythe development brief that was agreed at the time of commissioning. The developers haveworked with the Institute to ensure, in the time available, that the guideline has been subjected tovalidation and to consultation with stakeholders. However it has not been possible to subject it tothe full guideline development process that the Institute has now adopted.
INHERITED Clinical Guideline F
1.1 Evidence levels
1. Evidence
The definitions of the type of evidence used in this guideline (Table 1) originate fromthe US Agency for Health Care Policy and Research.
Table 1 Levels of evidence
Type of evidence
evidence from meta-analysis of randomised controlled trials evidence from at least one randomised controlled trial evidence from at least one controlled study without randomisation evidence from at least one other type of quasi-experimental study evidence from non-experimental descriptive studies, such as comparativestudies, correlation studies and case-control studies evidence from expert committee reports or opinions and/or clinical experience ofrespected authorities 1.2 Derivation and grading of recommendations
The grading scheme used in this guideline (Table 2) is from Eccles M et al. (1998).
Table 2 Grading of recommendations
Evidence (see Table 1):
•A directly based on category I evidence•B directly based on category II evidence, or extrapolated recommendation from •C directly based on category III evidence, or extrapolated recommendation from •D directly based on category IV evidence, or extrapolated recommendation from Eccles M et al. (1998) North of England Evidence Based Guideline Development Project: guideline for angiotensin converting enzyme inhibitors in primary care management of adults with symptomatic heart failure. British Medical Journal 316:1369.
2.1 Introduction
2. Guidance
2.1.1 Diabetes
Type 2 diabetes is affecting increasing numbers of people in the UK and the burden ofserious complications and their sequelae can be considerable both for the individualconcerned and the health service in general. Many aspects of these complications canbe limited, even prevented in some instances, with good early management of thecondition. The aim of these guidelines is to provide guidance about managing type 2diabetes for people with diabetes and the whole range of clinical staff who work inprimary and secondary care, in order to maximise the potential for reducingcomplications and improving the quality of life of people with the disease.
INHERITED Clinical Guideline F
This guideline is one of a series of five guidelines on type 2 diabetes. Other guidelines inthe series, due to be published in Spring 2002, cover the management of retinopathy,dyslipidaemia and blood pressure, and blood glucose. A guideline on foot care has beenpublished by the Royal College of General Practitioners. 2.1.2 Diabetic renal disease
Microalbuminuria is the earliest indicator of renal disease (nephropathy) attributable todiabetes. Microalbuminuria relates to a range of albumin values in the urine that, whilelow, are above normal levels. A review of longitudinal studies has shownmicroalbuminuria to be predictive of total mortality, cardiovascular mortality andcardiovascular morbidity.
Proteinuria, or macroalbuminuria, relates to a more extreme increase in the level ofalbumin in the urine. It represents a progression of urine albumin excretion frommicroalbuminuria. There is no definitive level of albumin to describe a clear cut-offpoint for proteinuria in the literature. There is also overlap between the albumin rangesused to define microalbuminuria and the cut-off points for proteinuria across somestudies.
People with type 2 diabetes can progress from proteinuria to end-stage renal failure,though this outcome is rare in comparison with cardiovascular mortality and morbidity.
Renal care for all people with type 2 diabetes
• Arrange recall and annual review for people with type 2 diabetes.•C• Review complications and risk factors at diagnosis and at least annually thereafter.•C• Measure urinary albumin:creatinine ratio or albumin concentration annually.•C - Use a first morning urine sample where practicable.•C - Use a laboratory or near-patient test specifically for microalbuminuria.•C • If microalbuminuria or proteinuria is present, repeat twice more (within 1 month • Measure serum creatinine annually.•C• Classify albumin excretion annually as: - lower risk (absence of microalbuminuria or proteinuria),•C or- higher risk (for definitions see box below).•C INHERITED Clinical Guideline F
Definitions used in this guideline
Diabetic renal disease
The presence of raised urine albumin levels and/or raised serum creatinine in type 2 diabetes indicates an increased risk of premature cardiovascular events and, to a lesser extent, end-stage renal disease. If the person also has signs of retinopathy, it is likely that the raised urine albumin and/or raised serum creatinine is resulting from diabetes-related renal disease. If retinopathy is not present, the probability of another Lower-risk urine albumin excretion
People who have levels of microalbuminuria and/or proteinuria lower than those
Higher-risk urine albumin excretion
Microalbuminuria - albumin:creatinine ratio greater than or equal to 2.5 mg/mmol (men)
or 3.5 mg/mmol (women), or albumin concentration greater than or equal to 20 mg/l Proteinuria - albumin:creatinine ratio greater than or equal to 30 mg/mmol or albumin
concentration greater than or equal to 200 mg/l.
2.3 Care for people with lower-risk albumin excretion
• Maintain good blood glucose control (preferably HbA below 6.5-7.5%, according • Maintain good blood pressure control (target blood pressure at or below 140/80 2.4 Care for people with higher-risk urine albumin excretion
• If retinopathy is not present, look for a non-diabetes-related cause of renal disease (full history and examination, urinalysis, renal ultrasound, other investigations asappropriate).•C • Ensure good blood glucose control (HbA below 6.5-7.5%, according to the • Measure, assess and manage cardiovascular risk factors aggressively.•A• Maintain blood pressure below 135/75 mmHg.•A• Begin therapy with an appropriate ACE inhibitor for cardiovascular/renal protection • ACE inhibitors are the drug class of first choice. To achieve target blood pressure, use combination therapy if ACE inhibitors alone are not fully effective. Combinationtherapy is likely to be necessary for most patients.•A • Measure urine albumin and serum creatinine levels at each visit.•C• Refer for specialist/nephrological opinion if serum creatinine greater than INHERITED Clinical Guideline F
Starting ACE inhibitor therapya in people with type 2 diabetes
ACE inhibitor therapy should be used with caution in those with: • peripheral vascular disease/renovascular disease For all people with type 2 diabetes, measure serum creatinine and electrolytes 1 week aSome ACE inhibitors are not licensed for use at the blood pressure levels recommended in this guideline.
These recommendations are derived from the guideline entitled Diabetic Renal Disease: 3. Full guideline
Prevention and Early Management commissioned from a collaboration between theRoyal College of General Practitioners, the Royal College of Physicians, the RoyalCollege of Nursing and Diabetes UK. This guideline is one of a series of five guidelineson type 2 diabetes. Other guidelines in the series, due to be published in Spring 2002,cover the management of retinopathy, dyslipidaemia and blood pressure, and bloodglucose. A guideline on foot care has been published by the Royal College of GeneralPractitioners. Diabetic Renal Disease: Prevention and Early Management is available onthe NICE website, www.nice.org.uk, and on the National Electronic Library forHealth's website, www.nelh.nhs.uk. The guideline developers are listed in Appendix A.
The five guidelines were commissioned by the Department of Health before theNational Institute for Clinical Excellence (NICE or 'the Institute') was formed in April1999. The developers have followed closely the development brief that was agreed atthe time of commissioning. The developers have worked with the Institute to ensure, inthe time available, that the guideline has been the subject of validation andconsultation with stakeholders. However, it has not been possible to subject it to thefull guideline development process that the Institute has now adopted.
This section of the national guideline for type 2 diabetes is aimed primarily at all healthcare professionals providing renal care to people with diagnosed type 2 diabetesin primary and secondary care, irrespective of location. Depending on the type, stageand severity of the clinical problem, the guideline may also be valuable to those whowork in diabetes care in the tertiary sector.
This guideline has been developed to advise on the care of adults with type 2 diabetes,but it may also help inform the care of those with type 1 diabetes. • definitions and epidemiology of renal disease in type 2 diabetes • screening for, and confirmation of, renal disease including screening methods • impact of screening on prognosis and management INHERITED Clinical Guideline F
• interventions and progression of renal disease - pre-disease (primary prevention)- established disease (secondary prevention).
Matters outside the scope of the guideline are listed below.
• This guideline does not provide detailed advice about the management of risk factors such as raised blood glucose levels, smoking, raised blood lipids or raised bloodpressure (which will be covered by other guidelines in this series). • It does not cover the management of end-stage renal disease, renal dialysis or renal • The guideline does not address the identification of undiagnosed diabetes or general management of people with diabetes (other than aspects that relate to the preventionand management of renal complications).
• This guideline does not address questions about the organisation and delivery of population-based or service-wide responses to the needs of people with diabetes.
This guideline is published as part of a range of clinical resources to support the DiabetesNational Service Framework. Its implementation should take place as part of the healthimprovement plans for each local health community. Local health communities will need to review existing service provision against this 5. Implementation in
guidance. This review should result in a strategy which identifies the resources required to implement fully the recommendations set out in Section 2 of the guidance, thepeople and processes involved and the timeline over which full implementation isenvisaged. Relevant local clinical guidelines and protocols should be reviewed in the light of thisguidance and revised accordingly. To enable clinicians to audit their own compliance with this guideline it isrecommended that, if not already in place, management plans are recorded for eachpatient. This information should be incorporated into local clinical audit data recordingsystems and consideration given (if not already in place) to the establishment ofappropriate categories in electronic record systems.
Prospective clinical audit programmes should record the proportion of patients whosecare adheres to the guidance. Such programmes are likely to be more effective inimproving patient care when they form part of the organisation's formal clinicalgovernance arrangements and where they are linked to specific postgraduate activities.
Selected key audit review criteria are shown in the box next page.
INHERITED Clinical Guideline F
Selected key audit criteria
Renal care for all people with type 2 diabetes
• The percentage of people with type 2 diabetes who have had their albumin:creatinine ratio or albumin concentration measured in the last 12 months.
• The percentage of people with type 2 diabetes who have had their serum creatinine • The percentage of people with type 2 diabetes who have had their albumin excretion classified as either lower risk or higher risk in the last 12 months (as defined in the Care for people with higher-risk albumin excretion
• The percentage of people with type 2 diabetes and higher-risk albumin excretion • The percentage of people with type 2 diabetes and higher-risk albumin excretion with blood pressure below 135/75 mmHg.
• The percentage of people with type 2 diabetes, higher-risk albumin excretion, and ser um crea tinine g rea ter than 150 µmol/l who have been refer red for In the course of developing the recommendations, the guideline developers considered the 6. Future research
following questions to be inadequately addressed by the available literature.
recommendations
• What are the differences in prevalence and progression of diabetic renal disease between different ethnic groups, and what are the reasons for these differences? • What are the optimum blood pressure targets to aim for in diabetic renal disease? • What is the impact of dyslipidaemia on renal disease in type 2 diabetes? • What is the role of thiazolidinediones in preventing proteinuria? • Are angiotensin-II receptor antagonists as good as ACE inhibitors, or are they best as Guidelines on the management of type 1 diabetes are being developed by the Institute and 7. Related NICE
will be available in late 2003/early 2004.
guidance
This guideline is one of a series of five guidelines on type 2 diabetes. Others in the series coverthe management of retinopathy, dyslipidaemia and blood pressure, and blood glucose; theseare due for publication in Spring 2002. A guideline on foot care has already been publishedby the Royal College of General Practitioners. INHERITED Clinical Guideline F
The Institute has published the following guidance on the use of rosiglitazone andpioglitazone in the treatment of type 2 diabetes mellitus. Both items of guidance are availablefrom the NICE website www.nice.org.uk, and paper copies can be ordered from the NHSresponse line, phone: 08701 555 455.
• National Institute for Clinical Excellence (August 2000) Guidance on the use of rosiglitazone for type 2 diabetes mellitus. Technology Appraisal Guidance No. 9.
London: NICE. Order ref. 22181.
• National Institute for Clinical Excellence (March 2001) Guidance on the use of pioglitazone for type 2 diabetes mellitus. Technology Appraisal Guidance No. 21London: NICE. Order ref. 23357.
The Institute's Guidance Executive will consider changes in the evidence base for this 8. Review date
guideline in March 2005. A decision will be made as to the need for and the extent of anyupdate.
INHERITED Clinical Guideline F
NHS
Clinical Excellence
National Institute for
gement of
type 2 dia
February 2002
Clinical Guideline
INHERITED
Treat as higher risk and refer for
specialist/nephrological opinion
Is serum creatinine greater than 150 mmol/l?
Measure serum creatinine
Maintain blood pressure below 135/75 mmHg
ACE inhibitors are first choice, but combination therapy is likely in most patients
Measure urine albumin and serum creatinine levels at each visit
Measure, assess and manage cardiovascular risk factors aggressively
Caution in patients with peripheral vascular disease/renovascular disease
Caution in patients with raised serum creatinine
initiating ACE inhibitor therapy
each increase in dose
Starting ACE inhibitor therapyb
Some ACE inhibitors are not licensed for use at the blood pressure levels recommended
in this guideline
In all patients, measure serum creatinine and electrolytes 1 week after:
NO (lower risk)
Maintain good blood glucose (HbA
6.5-7.5% according to the individual's target) and
good blood pressure control (at or below
140/80 mmHg)
albumin concentration:
below 6.5-7.5%, according to the individual's
Are 2 out of 3 tests positive
Algorithm for the prevention and management of renal disease in type 2 diabetes
Repeat tests twice within 1 month
Review complications and risk factors for renal disease on diagnosis of type 2 diabetes, and at least on an annual basis, as fo
Is microalbuminuria or proteinuria present?
Use a first morning urine sample where practicable
Use a laboratory or near-patient test specific for microalbuminuria
If retinopathy is not present, look for a non-diabetic cause of renal disease (full history and
examination, urinalysis, renal ultrasound, other investigations as appropriate)
Begin therapy with appropriate ACE inhibitor for cardiovascular/renal protection
Ensure tight blood glucose control (HbA
Measure urine albumin:creatinine ratio or
Definition of higher-risk urine albumin excretion
Higher risk
Microalbuminuria
Albumin:creatinine ratio ≥ 2.5 mg/mmol (men) or ≥ 3.5 mg/mmol (women)
albumin concentration ≥ 20 mg/l
Proteinuria
Albumin:creatinine ratio ≥ 30 mg/mmol
albumin concentration ≥ 200 mg/l
Spring 2002, cover the management of retinopathy guidelines on type 2 diabetes. Other guidelines in the series, due to be published in the Royal College of Nursing and Diabetes UK. between the Royal College of General Practitioners, the Royal College of Physicians, Disease: Prevention and Early Management The Institutes guideline is derived from the full guideline entitled development process that the Institute has now adopted.
for an English only version or ref. N0063 for an English/W necessary be interpreted with reference to the full guideline.
INHERITED
Issue date:
Renal disease - prevention and early management gement of
Review date:
Clinical Guideline
This guideline is one of a series of five organisations is permitted without the express written permission of the Institute.
Clinical Excellence
National Institute for
with the patient and/or guardian or carer This guidance is written in the following context:
National Electronic Library for Health' guideline on foot care has been published by the Royal Diabetic Renal Disease: Prevention and Early Appendix A
Guideline Development Group and Recommendations Panel
Renal Guideline Development Group
The Guideline Development Group is a multiprofessional team brought together on a project
basis to consider the evidence of clinical and cost effectiveness and develop the guideline. The
members of the Renal Guideline Development Group are listed below.
Dr Dennis Barnes
Professor Anthony Nicholls
Ms Val Brown
Diabetes Specialist Nurse
Dr Jean Peters
Dr Shirley Hopper
Department of Primary Care & General PracticeImperial College School of Medicine Professor GianCarlo Viberti
Professor of Diabetes & Metabolic MedicineKCLGuys Hospital Dr Sally Marshall (Chair)
Dr James Walker
Department of DiabetesEdinburgh Royal Infirmary Ms Aileen McIntosh
Senior Research Fellow and Programme ManagerSection of Public HealthScHARRUniversity of SheffieldSheffield Recommendations Panel
The production of the guidelines for type 2 diabetes is overseen by a Recommendations Panel,
which has ultimate responsibility for ensuring that a valid, relevant rigorous national clinical
guideline is produced as the result of the guideline development process. The Panel is also
responsible for the final grading of recommendations. Membership details of the
Recommendations Panel are listed in the full guideline.
INHERITED Clinical Guideline F
Appendix B
Guidelines Advisory Committee
The Guidelines Advisory Committee (GAC) is a standing committee of the Institute. It hasresponsibility for agreeing the scope and commissioning brief for clinical guidelines and formonitoring progress and methodological soundness. The GAC considers responses fromstakeholders and advises the Institute on the acceptability of the guidelines it has commissioned.
The members of the GAC are: Professor Stephanie A Amiel
Dr Fergus Macbeth
RD Lawrence Professor of Diabetic Medicine Professor James Mason
Mr Charles Collins
Chairman, Clinical Effectiveness Committee National Guidelines Support and Research Unit Mrs Joyce Cormie
Mrs Judy Mead
Head of Clinical Effectiveness Chartered Society of Physiotherapy Professor Mike Drummond
Director, Centre for Health Economics (CHE)
Ms Juliet Miller
DirectorScottish Intercollegiate Guidelines Network Professor Martin Eccles (Chair)
Professor of Clinical Effectiveness
Dr Chaand Nagpaul
Mr David Edwards
Chief Executive
Professor Robert Shaw
Postgraduate DeanPostgraduate Medical and Dental Education Professor Gene Feder (Vice-Chair)
Professor of Primary Care Research and
Miss Helen Spiby
Queen Mary's School of Medicine and Dentistry Mother and Infant Research Unit University of Leeds Professor Jeremy Grimshaw
Professor of Health Services Research and
Dr Jennifer Tyrrell
Programme Director in the Health Services Dr Gill Harvey
Mrs Amanda Wilde
Dr Bernard Higgins
Mrs Fiona Wise
Professor Allen Hutchinson
Dr John Young
Dr Marcia Kelson
Ms Carol Youngs
Director National Guidelines and Audit Patient INHERITED Clinical Guideline F
Appendix C
Screening for and early management of kidney (renal) problems -
a guide for adults with type 2 diabetes, and carers
The patient information in this appendix has been designed to support the production of your owninformation leaflets. You can download it from our website at www.nice.org.uk where it isavailable in English and Welsh. If you would like printed copies of the leaflets please ring theNHS Response Line on 0870 1555 455 and quote reference number N0062 for the Englishpatient leaflet and N0063 for the bi-lingual patient leaflet.
About this booklet
• is for adults with type 2 diabetes and their relatives and carers • describes the advice, treatment and care you should receive for the prevention and • is based on national evidence-based clinical guidelines on kidney care for people with Clinical guidelines exist to help healthcare teams and patients make the best decisions about About clinical
healthcare. They are developed by teams of healthcare professionals, patients and researchers guidelines
who look at the best evidence about care for a particular condition. Guidelines are recommendations for good practice. They are not intended to be a completedescription of a medical condition or disorder. They are not a substitute for patientpreference or clinical judgement. There may be good reasons why your treatment may differfrom the recommendations in this booklet.
Diabetes or, to give it its full name, diabetes mellitus is a common condition in which the What is diabetes?
amount of glucose (sugar) in the blood is too high because the body is unable to use itproperly. Normally, a person's pancreas (an organ in the body) produces a natural hormonecalled insulin, which controls the levels of glucose in the blood. Diabetes occurs when thebody does not produce enough insulin, or produces insulin but cannot use it properly. Thereare two types of diabetes.
Type 1 diabetes (also called insulin-dependent diabetes) occurs when there is a severe lack
of insulin in the body because most or all of the cells in the pancreas that produce it have
been destroyed. This type of diabetes usually appears in people under the age of 40, often in
childhood, and is treated by insulin injections and diet.
Type 2 diabetes (also called non-insulin-dependent diabetes) develops when the body can
still make some insulin, but not enough for its needs, or when the insulin that is produced
does not work properly (known as insulin resistance). This type of diabetes usually appears in
people over the age of 40, though it can appear in younger people.
Diabetes can cause a number of problems, which may affect: INHERITED Clinical Guideline F
• the levels of certain substances in the blood (for example, lipids such as cholesterol) • the kidneys (kidney problems are sometimes called nephropathy or renal disease).
This booklet describes the advice, treatment and care that adults with type 2 diabetes shouldreceive for the prevention and management of kidney (renal) disease.
Other booklets in the series will be published in Spring 2002, and will cover: • the prevention and management of eye problems (diabetic retinopathy) • the control of blood glucose (sugar) • blood pressure management and lipid management (for example, control of cholesterol One of the effects of type 1 and type 2 diabetes is that small blood vessels in the body may Diabetes and kidney
(renal) problems
Your kidneys keep the right amount of water in your body and help filter out harmful waste,
which then leaves the body as urine. Damage to the small blood vessels that supply blood to
the kidneys can cause the filtering process to stop working properly. When this happens
important proteins, such as albumin, are lost from the blood into the urine. Also waste
products, such as creatinine, are not removed properly. Damage to the kidneys is known as
nephropathy or renal disease.
Research shows that people with diabetes can reduce the risk of developing thesecomplications by: • controlling blood pressure and blood glucose levels (your healthcare professional will advise you on the levels you should be aiming to maintain) • managing your weight (your healthcare professional can advise you on an appropriate • maintaining good levels of physical activity (your health professional can advise you on appropriate exercise or fitness plans).
You are at a higher risk of having a kidney (renal) problem linked to your diabetes if you havediabetic retinopathy. You are also at increased risk the longer you have had diabetes and ifyou: • have high blood glucose (sugar) levels** • have high levels of certain lipids, such as cholesterol • are a man (but the other risk factors still apply to women) INHERITED Clinical Guideline F
• have a family history of kidney problems • have high levels of protein in your urine.
** High blood glucose or blood pressure levels for one person may be normal for another. To help prevent health problems associated with diabetes, including kidney problems, it is Annual check-ups for
important to monitor and manage your blood pressure and blood glucose (sugar) levels. all people with
If you have type 2 diabetes, you should expect to have your health reviewed every year. A diabetes
specially trained member of your healthcare team will look for any health problems or signsof problems or complications. The check-up may include: • carrying out tests to find out how well your kidneys are working • advice on your diet, exercise, weight reduction, stopping smoking, and to help you manage your blood pressure and blood glucose (sugar) levels yourself • advice on the need for any medicine or referral to a specialist.
This annual check-up is an opportunity for you to discuss any concerns or questions you mayhave. Not all the investigations will necessarily be carried out at the same time (for example,if you have recently undergone some of the tests between annual check-ups, these willprobably not be carried out again at your annual check).
Examinations and tests
The examinations and tests to check your kidneys may include the following.
• Testing a sample of your urine - you may be asked to supply a sample of your first morning urine so it can be tested for the protein albumin.
• Testing a blood sample for HbA (the abbreviation for glycosylated haemoglobin).
This is a hospital-based blood test that gives your average blood glucose result over thelast 2-3 months. This is to make sure that your blood glucose levels are under control,and to measure levels of other substances in your blood, including creatinine.
Your doctor/diabetes care team will use the levels of albumin in your urine and creatinine inyour blood to work out a figure called the 'albumin excretion level'. From this figure, yourdoctor can judge how well your kidneys are working and can discuss with you the mostsuitable care to meet your needs. Your doctor, or a member of your diabetes care team, should agree a plan of care with youthat covers: • how to manage your blood pressure and blood glucose (sugar) levels • any further monitoring, management or treatment that you need.
The need for further monitoring, management, treatment and follow-up appointments willdepend on the results of the tests performed at your check-up. INHERITED Clinical Guideline F
Summary of what to expect at your annual check-up
If you have type 2 diabetes a member of your healthcare team should: • arrange an appointment to check your health annually • take blood and urine samples to check your: and offer treatment to make sure healthy levels are maintained • discuss ways in which you can reduce the risk of developing heart problems, such - changing your diet, in particular, reducing the amount of salt you eat - taking more exercise (exercise can reduce your blood pressure) - reducing the amount of alcohol you drink INHERITED Clinical Guideline F
Monitoring and management of kidney problems
Tests carried out when you are first diagnosed with diabetes or at your annual health check-up measure levels of albumin or other proteins in your urine and levels of creatinine in yourblood. These will be used to calculate your albumin excretion level. Treatment will depend onwhether you have 'lower-risk' or 'higher-risk' levels and will depend also on whether or notyou have any eye damage (retinopathy).
A member of your healthcare team should:
Albumin or other proteins are present in Continue to check your health every year Agree a plan of care with you including advice on how to control your blood glucose and blood pressure levels You do not have signs of eye damage
disease not associated with your diabetes You do have signs of eye damage
(retinopathy) and have higher risk albumin Offer treatment with 'ACE inhibitors',medicines that help your blood flow more efficiently. (ACE stands for angiotensin converting enzyme). Blood samples should be taken 1 week after you start this treatment and whenever the dose is increased Offer a combination of drugs if ACE inhibitors alone are not fully effective Take urine and blood samples to measure your albumin and creatinine levels at each visit Measure, assess and manage your risk ofheart disease (see the separate booklet on the management of dyslipidaemia and blood pressure) INHERITED Clinical Guideline F
You have the right to be fully informed and to share in decision-making about your Further information
healthcare. If you need further information about any aspects of your diabetes or treatment,please ask your GP or a relevant member of your healthcare team. You can discuss thisguideline with them if you wish.
For further information about the National Institute for Clinical Excellence (NICE), theClinical Guidelines Programme or other versions of this guideline (including the sources ofevidence used to inform the recommendations for treatment and care), you can visit theNICE website at www.nice.org.uk. Copies of the full guideline can be obtained from the NHS Response Line by telephoning Ordering information
0870 1555 455 and quoting ref. N0061. Further copies of the patient information can alsobe obtained by quoting ref. N0062.
This patient information is also available in Welsh, ref. N0063.
Mae'r daflen hon hefyd ar gael yn Gymraeg, rhif N0063.
The advice in this patient information is adapted from Clinical Guidelines for Type 2 Diabetes. RenalDisease, Prevention and Management. . Sheffield: Effective Clinical Practice Unit, Royal College of GeneralPractitioners, 2002, which has been produced by a collaboration between the Royal College of GeneralPractitioners, the Royal College of Physicians, the Royal College of Nursing and Diabetes UK, on behalf ofthe National Institute for Clinical Excellence (NICE). INHERITED Clinical Guideline F

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