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Question: When is it appropriate to restrict protein for patients with diabetes and albuminuria?
Answer: In individuals with earlier stages of renal disease, reduction of dietary protein to 0.8–1.0 g/kg body weight per day may improve measures of renal function (i.e., urine albumin excretion rate and glomerular filtration rate [GFR]) (see list of classifications below).1 It's equally important to manage hypertension and restrict dietary sodium to approximately 2,000 mg/day.2
For patients in later stages of renal disease, key nutritional considerations include careful monitoring and restriction of protein in addition to restriction of sodium, potassium, and phosphorus. Further reduction of protein to 0.6 g/kg body weight per day in patients with kidney failure may be beneficial.2 These patients may experience weight loss and malnutrition without nutrition intervention. Since hypoalbuminemia is highly predictive of future mortality risk when present at the time dialysis is initiated, it's important to monitor patients closely to avoid it.3
Optimal treatment of diabetic renal disease includes medications to control blood pressure and glucose and appropriate nutrition management.4 Given that diabetes accounts for 44% of end-stage renal disease, patients should be screened routinely and referred early.5
The American Diabetes Association recommends the following screenings:1
Microalbuminuria can be screened by the following methods:
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WHEN TO REFER
A timely referral to a renal specialist may help slow the progression of renal disease. Refer when the GFR has fallen to <60 ml/min or if the patient is experiencing difficulties managing hypertension, hyperkalemia, hyperphosphatemia, secondary hyperparathyroidism, or anemia.
Individuals with renal disease often have a compromised nutritional status.
Physicians should refer these patients to a registered dietitian skilled in
renal disease management and diabetes who can develop an integrated medical
nutrition therapy plan to meet individual nutritional needs. 
Footnotes
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References
2. Levey AS, Bosch JP, Lewis JB, et al., for the Modification of Diet
in Renal Disease Study Group: A more accurate method to estimate glomerular
filtration rate from serum creatinine: A new prediction equation.
Ann Intern Med 130:461–470, 1999.
3. National Kidney Foundation: Kidney disease outcomes quality initiative (K/DOQI) adult guidelines 2000: Maintenance dialysis: Evaluation of protein-energy nutritional status. Available online at www.kidney.org/professionals/kdoqi/guidelines/nut_a03.html Accessed October 19, 2006.
4. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 14:977–986, 1993.
5. Gross JL, de Azevedo MJ, Silveiro SP, et al.: Diabetic nephropathy:
Diagnosis, prevention, and treatment. Diabetes Care 28: 164–176, 2005.
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