Monitoring

  • Hemoglobin A1c (HbA1c) should be checked at least twice per year in patients with diabetes who are meeting their glycemic targets, or quarterly (four times per year) in patients who have recently changed medication and/or who are not meeting glycemic targets.[1][47]

  • Blood pressure (BP) should be checked at each primary care visit.[1]

  • Lipids should be checked at diabetes diagnosis and then annually; this may need to be done at more frequent intervals in patients on statins or other lipid-lowering therapy to check treatment goals.​​[1][134]​​ Less frequent lipid monitoring may be appropriate for patients at lower cardiovascular risk (e.g., not on statins or lipid-lowering therapy, age <40 years).[1]

  • In people with established DKD, urinary albumin (e.g., spot urinary albumin to creatinine ratio [ACR]) and estimated glomerular filtration rate (eGFR) should be monitored 1-4 times per year, depending on the stage of the disease.[1]

  • When eGFR is <60 mL/minute/1.73 m², screening for complications of chronic kidney disease (CKD), such as hypertension, volume overload, electrolyte imbalance, metabolic acidosis, anemia, and metabolic bone disease, is indicated.[1]

  • Referral to a nephrologist should be considered if a patient with diabetes has continuously rising urinary ACR levels and/or continuously declining eGFR, if there is uncertainty about the etiology of kidney disease, for difficult management issues (anemia, secondary hyperparathyroidism, significant increases in albuminuria in spite of good BP management, metabolic bone disease, resistant hypertension, or electrolyte disturbances), or when there is advanced kidney disease (eGFR <30 mL/minute/1.73 m²) requiring discussion of renal replacement therapy for end-stage kidney disease.[1] Consultation with a nephrologist when stage 4 DKD develops (eGFR <30 mL/minute/1.73 m²) has been found to reduce cost, improve quality of care, and delay dialysis.[1]

  • Advanced DKD is often associated with diabetic retinopathy because of microvascular disease. In the US, screening for diabetic retinopathy is recommended within 5 years of initial diagnosis of diabetes for adults with type 1 diabetes, and at diagnosis for adults with type 2 diabetes, and then every 1-2 years thereafter if there is no evidence of retinopathy.[1] More frequent follow-up may be required (e.g., annually) if findings are abnormal.[1]

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