Early diagnosis of chronic kidney disease in patients with diabetes in France: multidisciplinary expert opinion, prevention value and practical recommendations

Figures & data

Figure 1. KDIGO GA matrix according to eGFR and albuminuria stages. [1]. Heat map reflects the risk of progression by intensity of coloring (green: low risk [if no other markers of kidney disease, no CKD]; yellow: moderately increased risk; orange: high risk; red/deep red, very high risk). The numbers in the boxes are a guide to the frequency of monitoring (number per year). Treatment and referral indications are given in plain text (with the publisher permission).

Abbreviations: CKD: chronic kidney disease; GFR: glomerular filtration rate; KDIGO: Kidney Disease Improving Global Outcomes; UACR: urine albumin-to-creatinine ratio.

Table 1. Situations in which CKD screening is recommended by HAS 2021 [28]. Screening includes plasma creatinine assay to estimate GFR and urine albumin-to-creatinine ratio (UACR). Screening is recommended once a year for all patients with diabetes and, at the time of diagnosis, then every five years (if initially normal) in hypertensive patients. The three first conditions (bold text) represent ~ 90% of patients diagnosed with CKD.

1	Diabetes (every year)
2	Hypertension (at diagnosis and every 5 years thereafter)
3	Age >60 years
4	Obesity >30 kg/m^2
5	Cardiovascular disease
6	Family history of chronic renal failure (e.g. polycystic kidney disease)
7	Obstructive uropathy
8	Systemic/inflammatory diseases (e.g. myeloma, lupus, amyloidosis)
9	Nephrotoxic drugs (e.g. non-steroidal anti-inflammatory drugs, COXIB, lithium, iodinated contrast products)
10	History of acute renal failure

Table 2. Referral to a nephrologist based on the guidelines for CKD management established by the French National Authority for Health [28]. These recommendations generally suggest referring patients at late stages of CKD (1-5-8), which misses opportunities for optimal pharmacological interventions. The use of the KFRE could replace recommendations 1, 3 and 4.

1	eGFR <45 mL/min/1.73 m^2
2	UACR >500 mg/g (>45 mg/mmol)
3	Rapid decline in eGFR: annual loss >5 ml/min/1.73 m^2
4	Decline in eGFR > 30% in 4 months without obvious explanation
5	Complications (hyperkalemia >5.5 mmol/l resistant to treatment; anemia, etc.)
6	Resistant hypertension
7	A doubt about the cause or management in a patient with suspected renal disease
8	Suspicion of hereditary nephritis/lithiasis, monoclonal gammopathy
9	Potential eGFR <20 ml/min/1.73 m^2 or renal replacement therapy within the next 12 months

Abbreviations: CKD: chronic kidney disease; eGFR: estimated glomerular filtration rate; UACR: urine albumin-to-creatinine ratio.

Figure 2. Coordinated care pathway model for CKD in patients with diabetes.

Abbreviations: eGFR: estimated glomerular filtration rate; GFR: glomerular filtration rate; KFRE: Kidney Failure Risk Equation; UACR: urine albumin-to-creatinine ratio.

Table 3. Expert recommendations to improve the management of CKD in patients with T2D.

1	To raise awareness of kidney disease among healthcare providers, including nurses and pharmacists
2	To improve the fragmented journey of the diabetic patient using a well-coordinated multidisciplinary and pluriprofessional approach
3	To improve poor and late follow-up of kidney disease in patients with diabetes
4	To facilitate access of patients to the specialist, including the set-up of a helpline for nephrology advice
5	To strengthen patient autonomy and promote therapeutic education
6	To involve local health professionals as much as possible in the management of CKD in patients with diabetes
7	To standardize the practice of lab specialists: • To assess eGFR using the CKD-EPI equation and validated analytic methods • To measure UACR on spot urine expressed in mg/g, instead of proteinuria • To calculate slopes of eGFR with an automatic calculation of the annual decline of eGFR • To calculate the KRFE score with comments for referral • To help clinicians by indicating ‘Think about rechecking eGFR’ when eGFR is found abnormal for the first time in a patient • Implement a comment ‘Mind about measuring UACR’ when eGFR or HbA1c is found abnormal for the first time
8	To inform healthcare professionals on the availability of additional biological parameters and tools to promote early detection and monitoring of CKD: • To advise on the follow-up frequency of laboratory tests according to KDIGO guidelines • Calculator of the renal function decline: https://www.sfdiabete.org/renalfunctiondeclinecalculator • Monitoring graph of eGFR with a non-linear scale for a more accessible demonstration of renal function decline • eGFR slope as a predictive indicator of cardiovascular risk and mortality by differentiating steep slope versus chronic slope • KFRE: ∘ https://kidneyfailurerisk.com ∘ https://qxmd.com/calculate/calculator_308/kidney-failure-risk-equation-4-variable (also available as a mobile application: QxMed)
9	To develop a map of biological parameters by region in France to draw the attention of Regional Health Authorities on kidney diseases

Abbreviations: CKD: chronic kidney disease; CKD-EPI: chronic kidney disease-epidemiology collaboration; eGFR: estimated glomerular filtration rate; KeGFR: kinetic estimated glomerular filtration rate; KeUACR: kinetic urine albumin-to-creatinine ratio; KFRE: Kidney Failure Risk Equation; T2D: type 2 diabetes; UACR: urine albumin-to-creatinine ratio.

Rossing P, Caramori ML, Chan JCN, et al. Executive summary of the KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease: an update based on rapidly emerging new evidence. Kidney Int. 2022;102(5):990–999. PMID: 36272755. doi: 10.1016/j.kint.2022.06.013

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