Management of diabetic kidney disease in clinical practice: SBD Guidelines
Brazil: An evidence-based guideline, published in the journal Diabetology & Metabolic Syndrome, provides guidance on the correct management of diabetic kidney disease (DKD) in clinical practice. The 2021–2022 position covers screening and treatment of hyperglycemia, arterial hypertension, and dyslipidemia in the patient with diabetic kidney disease.
Diabetic kidney disease is the leading cause of end-stage renal disease and is associated with increased morbidity and mortality. The review is an authorized literal translation of part of the Brazilian Diabetes Society (SBD) Guidelines 2021–2022. The extensive review of the literature made by the 14 members of the Central Committee defined 24 recommendations.
RECOMMENDATIONS
DKD Screening
R1 -- The first screen for DKD IS RECOMMENDED to be at the diagnosis in T2DM, and after 5 years from diagnosis in people with T1DM, starting at 11 years of age.
R2 -- IT IS RECOMMENDED to perform an annual screening of DKD with the measurement of albumin or albumin/creatinine ratio in a urine sample, together with the estimation of GFR with the serum creatinine-based CKD-EPI equation.
Treatment of Hyperglycemia in DKD on Dialysis Patients
R11 -- In individuals with T2DM on dialysis and HbA1c above the target, IT IS RECOMMENDED the use of insulin as a priority.
Treatment of Hypertension in DKD
R13 -- Intensive treatment of hypertension is RECOMMENDED due to the cardiovascular benefits and the evolution of DKD.
R14 -- A blood pressure goal < 130/80 mmHg IS RECOMMENDED for patients with DKD who can reach this goal without side effects.
R15 -- A blood pressure goal < 130/80 mmHg IS RECOMMENDED for adult patients with DM and increased risks of stroke and atherosclerotic cardiovascular disease.
R16 -- It is RECOMMENDED to use angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) for patients with albuminuria, to reduce kidney disease progression, regardless of blood pressure levels.
R18 -- The use of mineralocorticoid receptor antagonists SHOULD BE CONSIDERED for blood pressure control and renal protection, in association with ACEIs or ARBs in patients with GFR ≥ 25 mL/min/1.73 m2 and serum potassium levels <5.0 mEq/L.
R19 -- The use of non-steroidal mineralocorticoid receptor antagonists MAY BE CONSIDERED for renal protection, in association with ACEIs or BRAs, in patients with GFR ≥ 25 mL/min/1.73 m2 , with serum potassium levels <5.0 mEq/L.
R20 -- In patients with DKD and eGFR < 60 mL/min/1.73 m2 and post-transplanted patients, the use of high-potency statins IS RECOMMENDED to reduce cardiovascular events.
Patients with DKD on Dialysis
R21 -- In patients with DKD on dialysis, without clinical arterial disease, IT IS NOT RECOMMENDED to start using statins. However, in patients who were already using a statin before starting dialysis, it should be continued.
R22 -- In patients on hemodialysis and LDL-c above 145 mg/dL and/or with established coronary artery disease, statin initiation MAY BE CONSIDERED.
R23 -- For individuals with non-dialysis-dependent advanced CKD, it is RECOMMENDED a dietary protein intake of around 0.8 g/kg ideal body weight per day.
R24 -- The limit for a sodium intake of up to 1.5 g/day, or of salt, up to 3.75 g/day, SHOULD BE CONSIDERED when there is arterial hypertension.
The team wrote in the their conclusion, to prevent or at least postpone the advanced stages of DKD with the associated cardiovascular complications, intensive glycemic and blood pressure control are required, as well as the use of renin–angiotensin–aldosterone system blocker agents such as ARB, ACEI, and MRA."
"Recently, SGLT2 inhibitors and GLP1 receptor agonists have been added to the therapeutic arsenal, with well-proven benefits regarding kidney protection and patients' survival."
Reference:
de Sá, J.R., Rangel, E.B., Canani, L.H. et al. The 2021–2022 position of Brazilian Diabetes Society on diabetic kidney disease (DKD) management: an evidence-based guideline to clinical practice. Screening and treatment of hyperglycemia, arterial hypertension, and dyslipidemia in the patient with DKD. Diabetol Metab Syndr 14, 81 (2022). https://doi.org/10.1186/s13098-022-00843-8
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