(9) Microvascular complications and foot care.

Treatment c Optimize glucose control to reduce the risk or slow the progression of diabetic kidney disease. A c Optimize blood pressure control (,140/90 mmHg) to reduce the risk or slow the progression of diabetic kidney disease. A c For people with nondialysis-dependent diabetic kidney disease, dietary protein intake should be 0.8 g/kg body weight per day (the recommended daily allowance). For patients on dialysis, higher levels of dietary protein intake should be considered. A c Either an ACE inhibitor or an angiotensin receptor blocker is recommended for the treatment of nonpregnant patients with diabetes and modestly elevated urinary albumin excretion (30–299 mg/day) B and is strongly recommended for those with urinary albumin excretion $300 mg/day and/or estimated glomerular filtration rate ,60 mL/min/1.73 m. A c Periodically monitor serum creatinine and potassium levels for the development of increased creatinine or changes in potassium when ACE inhibitors, angiotensin receptor blockers, or diuretics are used. E c Continued monitoring of urinary albumin–to–creatinine ratio in patients with albuminuria treatedwith an ACE inhibitor or an angiotensin receptor blocker is reasonable to assess the response to treatment and progression of diabetic kidney disease. E c An ACE inhibitor or an angiotensin receptor blocker is not recommended for the primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure, normal urinary albumin–to–creatinine ratio (,30 mg/g), and normal estimated glomerular filtration rate. B c When estimated glomerular filtration rate is ,60 mL/min/1.73 m, evaluate and manage potential complications of chronic kidney disease. E c Patients should be referred for evaluation for renal replacement treatment if they have estimated glomerular filtration rate ,30 mL/min/1.73 m. A c Promptly refer to a physician experienced in the care of kidney disease for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease. B