Box 1.

Standards of care for diabetes with chronic kidney disease

CKD: Identify persistent progressive decline in eGFR >10 mL/min/1.73 m2 over 2 years.
ACR: Identify progressive increase from >2.5 mg/mmol to >10 mg/mmol (women) and >3.5 mg/mmol to >30 mg/mmol (men).
Blood pressure: 140/90 mmHg (130/80 mmHg if albuminuria present) attainment.
Non-HDL cholesterol: 2.5 mmol/L attainment.
HbA1c: 58–68 mmol/mol (7.5–8.5%) attainment, especially in hypoglycaemia risk reduction.
Hypoglycaemia enquiry record.
Haemoglobin: Check if <110 g/L haematinic check and management if iron deficient; consider in HbA1c assessment.
Record Read-coded cerebrovascular disease status accurately.
Record Read-coded coronary artery disease and heart failure status accurately.
Foot care: Podiatry should be considered unless recorded as no neuropathy/peripheral vascular disease.
Aspirin (or alternative antiplatelet use) unless contraindicated, for those with albuminuria and/or CVD.
Record if BMI >30 kg/m 2 and weight-reducing input and selection of weight-neutral or reducing therapies in diabetes and CKD with obesity.
Record of smoking cessation input for smokers.
Retinopathy status recorded in care plan and recognition of proliferative retinopathy/maculopathy with respect to glycaemic management.
Annual measurement of calcium, vitamin D and parathyroid hormone levels if CKD 3b or worse and use of activated vitamin D in normocalcaemic secondary hyperparathyroidism where parathyroid hormone 2–9 times the upper limit of the reference range.
Referral to renal department with deteriorating eGFR, eGFR <30 mL/min/1.73 m 2, nephrotic range proteinuria, unexplained anaemia, hyperparathyroidism, uncontrolled hypertension.
Referral to specialist diabetes service with active foot and retinal complications, recurrent hypoglycaemia, HbA1c >75 mmol/mol, especially if ACR >30 mg/mmol and/or CKD 3b (eGFR 30–45 mL/min/1.73 m 2).
  • BMI = body mass index; CKD = chronic kidney disease; CVD = cardiovascular disease; eGFR = estimated glomerular filtration rate; HbA1c = haemoglobin A1c; HDL = high-density lipoprotein; ACR = urine albumin:creatinine ratio.