Diabetes: Medical Attention for Nephropathy

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period

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As the seventh leading cause of death in the U.S., diabetes kills approximately 79,500 people a year (CDC Health 2017). Diabetes is a long lasting disease marked by high blood glucose levels, resulting from the body's inability to produce or use insulin properly (CDC About Diabetes 2017). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney failure, amputation of toes, feet or legs, and premature death. (CDC At a Glance 2016). 

In 2012, diabetes cost the U.S. an estimated $245 billion: $176 billion in direct medical costs and $69 billion in reduced productivity. This is a 41 percent increase from the estimated $174 billion spent on diabetes in 2007 (ADA Economic 2013).  

High blood sugar levels in patients with diabetes put them at a higher risk of damaging their kidneys and causing chronic kidney disease, which can lead to kidney failure (CDC Fact Sheet 2017, CDC At a Glance 2016). During 2011-2012 there were 36.5% new cases of chronic kidney disease (stages 1-4) among 297,000 diabetic patients 20 years and older (Murphy 2016). In 2014, diabetes accounted for 44% of 118,000 new cases of end stage renal disease (USRDS 2016).

American Diabetes Association (2017):

Screening
- At least once a year, assess urinary albumin (eg, spot urinary albumin-to-creatinine ratio [UACR]) and estimated glomerular filtration rate (eGFR) in patients with type 1 diabetes duration of greater than or equal to 5 years in all patients with type 2 diabetes, and in all patients with comorbid hypertension. (Level of evidence: B)

Treatment
- An angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) is not recommended for the primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure, normal UACR (<30 mg/g creatinine), and normal estimated glomerular filtration rate. (Level of evidence: B)
- Either an ACE inhibitor or ARB is suggested for the treatment of the nonpregnant patient with modestly elevated UACR (30-299 mg/g creatinine) (Level of evidence: B) and is strongly recommended for those with urinary albumin to creatinine ratio >=300 mg/g creatinine and/or estimated glomerular filtration rate < 60 mL/min/1.73.m2. (Level of evidence: A)
- When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels for the development of increased creatinine or changes in potassium. (Level of evidence: E)
- Continued monitoring of UACR in patients with albuminuria treated with an ACE inhibitor or ARBs is reasonable to assess the response to treatment and progression of diabetic kidney disease. (Level of evidence: E)

American Association of Clinical Endocrinologists (2015): 
- Beginning 5 years after diagnosis in patients with type 1 diabetes (if diagnosed before age 30) or at diagnosis in patients with type 2 diabetes and those with type 1 diabetes diagnosed after age 30, annual assessment of serum creatinine to determine the estimated glomerular filtration rate (eGFR) and urine albumin excretion rate (AER) should be performed to identify, stage, and monitor progression of diabetic nephropathy (Grade C; best evidence level 3). 
- Patients with nephropathy should be counseled regarding the need for optimal glycemic control, blood pressure control, dyslipidemia control, and smoking cessation (Grade B; best evidence level 2). 
- In addition, they should have routine monitoring of albuminuria, kidney function electrolytes, and lipids (Grade B; best evidence level 2). 
- Associated conditions such as anemia and bone and mineral disorders should be assessed as kidney function declines (Grade D; best evidence level 4). 
- Referral to a nephrologist is recommended well before the need for renal replacement therapy (Grade D; best evidence level 4).

Higher score indicates better quality

American Diabetes Association. Microvascular complications and foot care. Sec. 10. In Standards of Medical Care in Diabetes-2017. Diabetes Care 2017;40(Suppl. 1):S88-S98.

American Diabetes Association (ADA). April 2013. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. Vol. 36 no. 4 1033-46. http://care.diabetesjournals.org/content/36/4/1033.full.

Centers for Disease Control and Prevention (CDC). 2017. About Diabetes. https://www.cdc.gov/diabetes/basics/diabetes.html.

Centers for Disease Control and Prevention (CDC). 2017. National Chronic Kidney Disease Fact Sheet. https://www.cdc.gov/diabetes/pubs/pdf/kidney_factsheet.pdf.

Centers for Disease Control and Prevention (CDC). 2016. At a Glance 2016, Diabetes Working to Reverse the US Epidemic. https://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/2016/diabetes-aag.pdf.

Centers for Disease Control and Prevention (CDC). 2017. Health, United States, 2016: With Chartbook on Long-term Trends in Health. https://www.cdc.gov/nchs/data/hus/hus16.pdf#019.  

Murphy D, McCulloch CE, Lin F, et al. Trends in prevalence of chronic kidney disease in the United States. Ann Intern Med. 2016;165:473-481.

United States Renal Data System (USRDS). 2016. 2016 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

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Only patients with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of this measure; patients with a diagnosis of secondary diabetes due to another condition should not be included

TBD

Patients 18-75 years of age with diabetes with a visit during the measurement period

Equals Initial Population

Exclude patients whose hospice care overlaps the measurement period

Patients with a screening for nephropathy or evidence of nephropathy during the measurement period

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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