OBJECTIVE -To determine the prevalence and characteristics of patients with type 2 diabetes who have impaired renal function, defined as a glomerular filtration rate (GFR) Ͻ60 ml ⅐ min Ϫ1 ⅐ 1.73 m Ϫ2 , and normoalbuminuria. RESEARCH DESIGN AND METHODS-A cross-sectional survey of 301 outpatients attending a single tertiary referral center using the plasma disappearance of isotopic 99m Tcdiethylene-triamine-penta-acetic acid to measure GFR and at least two measurements of urinary albumin excretion rate (AER) over 24 h to determine albuminuria.RESULTS -A total of 109 patients (36%) had a GFR Ͻ60 ml ⅐ min Ϫ1 ⅐ 1.73 m Ϫ2 . The overall prevalence of normo-, micro-, and macroalbuminuria was 43 of 109 (39%), 38 of 109 (35%), and 28 of 109 (26%), respectively. Compared with patients with macroalbuminuria, those with normoalbuminuria were more likely to be older and female. After excluding patients whose normoalbuminuric status was possibly related to the initiation of a renin-angiotensin system (RAS) inhibitor before the start of the study, the prevalence of a GFR Ͻ60 ml ⅐ min Ϫ1 ⅐ 1.73 m Ϫ2and normoalbuminuria was 23%. Temporal changes in GFR in a subset of 34 of 109 (32%) unselected patients with impaired renal function were available for comparison over a 3-to 10-year period. The rates of decline in GFR (ml ⅐ min Ϫ1 ⅐ 1.73 m Ϫ2 ⅐ year Ϫ1 ) of Ϫ4.6 Ϯ 1.0, Ϫ2.8 Ϯ 1.0, and Ϫ3.0 Ϯ 07 were not significantly different for normo-(n ϭ 12), micro-(n ϭ 12), and macroalbuminuric (n ϭ 10) patients, respectively.CONCLUSIONS -These results suggest that patients with type 2 diabetes can commonly progress to a significant degree of renal impairment while remaining normoalbuminuric. Diabetes Care 27:195-200, 2004A reduced glomerular filtration rate (GFR), mainly estimated from creatinine clearance measurements, has been reported to occur in some longstanding normoalbuminuric type 1 diabetic patients (1,2). Work from our group has suggested that this phenomenon can also occur in both type 1 or type 2 diabetes and that it may be more common in type 2 diabetes (3). Furthermore, in comparison to patients with type 1 diabetes, albuminuric patients with type 2 diabetes have a great deal of renal ultrastructural heterogeneity (4,5). This structural heterogeneity raises the possibility that different GFR and AER relationships are seen in patients with type 2 compared with those with type 1 diabetes. We have therefore further investigated the association between GFR and AER in patients with type 2 diabetes. In particular, we determined the prevalence and characteristics of patients with impaired renal function, defined as a GFR Ͻ60 ml ⅐ min Ϫ1 ⅐ 1.73 m Ϫ2 , and an AER within the normoalbuminuric range. RESEARCH DESIGN ANDMETHODS -A total of 625 patients attending the diabetes clinic at Austin Health, a tertiary referral center and teaching hospital of The University of Melbourne, Victoria, Australia, were studied between 1990 and 2001 as part of an ongoing project investigating the pathogenesis of diabetic renal disease. Isotopic estimations o...

GUIDELINES SUGGESTIONS FOR CLINICAL CARE• Screening for microalbuminuria and glomerular filtration rate (GFR) should be preformed on an annual basis from the time of diagnosis of type 2 diabetes.• ACR should be measured using a morning urine sample, however, random urine samples can be used.• Measurement of urinary albumin can be influenced by a number of factors including:-urinary tract infection, -high dietary protein intake,-congestive heart failure, -acute febrile illness, -menstruation or vaginal discharge, -water loading, and -drugs (NSAIDS, ACEi).• Tests such as albumin concentration >20 mg/litre or a dipstick test for albuminuria are semi-quantitative and should be confirmed by ACR or AER measurements.• GFR is most commonly estimated using the Modification of Diet in Renal Disease (MDRD) equation which is based on serum creatinine, age and sex. The MDRD NEPHROLOGY 2010; 15, S146-S161 doi:10.1111/j.1440-1797.2010.01239.x © 2010 The Authors Journal compilation © 2010 Asian Pacific Society of Nephrology formula tends to underestimate GFR at levels greater than 60 mL/min but is more accurate at lower levels.• GFR can be estimated using the Cockcroft-Gault (CG) formula, which is based on serum creatinine, age, sex and body weight. The CG formula tends to underestimate GFR at levels less than 60 mL/min but is more accurate at higher levels.• BACKGROUND Aim of the guidelineThis guideline topic has been taken from the NHMRC 'National Evidence Based Guidelines for Diagnosis, Prevention and Management of CKD in type 2 diabetes' which can be found in full at the CARI website (http:// www.cari.org.au). The NHMRC guideline covers issues related to the assessment and prevention of CKD in individuals with established type 2 diabetes. The NHMRC guidelines do not address the care of people with diabetes who have end-stage kidney disease (ESKD) or those who have a functional renal transplant. In addition, the present guideline does not provide recommendations regarding the management of individuals with established CKD, with respect to the prevention of other (non-renal) adverse outcomes, including retinopathy, hypoglycaemia, bone disease and cardiovascular disease. It is important to note however, that in an individual with type 2 diabetes, the prevention of these complications may be a more important determinant for their clinical care. Consequently, the recommendations made must be balanced against the overall management needs of each individual patient.How should kidney function be assessed and how often in people with type 2 diabetes?Screening for CKD aims to identify abnormal urine albumin excretion and declining GFR, so that interventions can be given to slow progression of kidney disease, to prevent ESKD and to reduce the risk of CVD. Assessment of kidney function in people with type 2 diabetes includes measurement of urinary albumin excretion and estimation of GFR for the purposes of screening, diagnosis and monitoring response to management.In a significant proportion of people with type 2 diabetes, CKD may ...