Type 1 and type 2 diabetes are considered coronary heart disease (CHD) risk equivalents, due to the strong association of diabetes and serious cardiovascular disease. Type 2 diabetes is associated with other CHD risk factors such as elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides. Lipid disorders should be managed aggressively in diabetic patients [...]
Nov 042010
Microalbuminuria (30–300 mg/24 hour), the earliest stage of kidney disease associated with diabetes, often progresses to clinical albuminuria (greater than 300 mg/24 hours) with a subsequent decline in renal function over a period of years. Hypertension usually develops during the onset of microalbuminuria and, if left untreated, can hasten progression of renal disease. Prevention and treatment recommendations for diabetic nephropathy include:
• Maximize glycemic control to delay onset of microalbuminuria.
• Annually screen for microalbuminuria in all type 2 diabetics, in type 1 diabetics beginning five years after diagnosis, and for gestational diabetes. The recommended method for screening for microalbuminuria in the BOP is by measurement of the albumin-to-creatinine ratio in a random spot collection. Clinical microalbuminuria is defined as the occurrence of elevated albumin-to-creatinine ratio for two of three tests within a six-month period. Measurement of spot urine for albumin only is not recommended.
• Measure serum creatinine annually to calculate a glomerular filtration rate (GFR).
Serum creatinine alone is not an adequate measure of kidney function. Studies have found a decreased GFR in the absence of increased urine albumin excretion in a substantial percentage of adults with diabetes. All diabetic inmates should have a GFR calculated at baseline and annually. The GFR can be calculated utilizing an internet calculator from the National Kidney Foundation
• The stages of chronic kidney disease based on GFR are outlined in Table 7 below. A nephrologist should be consulted if the GFR is <30 ml/min per 1.73 m
• Regardless of blood pressure status, treat diabetics with microalbuminuria with ACE
inhibitors (unless medically contraindicated). An ARB should be considered if ACE inhibitors cannot be tolerated or are contraindicated. Monitor for hyperkalemia.
• Lower blood pressure to <130/80, using multi-drug therapy if necessary.
• Restrict protein intake for diabetic inmates with the onset of nephropathy.
• Avoid metformin in patients with elevated creatinine levels (>1.5 mg/dl in men, or >1.4 mg/dl in women) because of increased risk of acidosis.
 Aspirin TherapyClinical trials have demonstrated that aspirin therapy is a cheap and effective intervention for preventing serious cardiovascular events such as myocardial infarctions and stroke among diabetics. Enteric coated aspirin in dosages of 81–162 mg/day should be considered a standard part of treatment for most diabetic patients. Aspirin is indicated for the following diabetic inmates unless [...] |
 Monitoring and Treatment During PregnancyThe following guidelines should be considered when managing inmates with GDM: • Close surveillance of the mother and fetus must be maintained throughout the pregnancy. Self-monitoring of blood glucose should be done on a frequent (daily) basis. Use of post-prandial monitoring is preferred. Monitoring of urinary glucose is not an adequate measure. • Screening for [...] |