Management of diabetic kidney disease in clinical practice: SBD Guidelines

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.

R3 -- IT IS RECOMMENDED that any abnormal test of the albumin/creatinine ratio (above 30 mg/g) or albumin concentration (above 30 mg/L) be confirmed in at least two out of three samples collected with an interval of three to six months because of the high daily variability.

Treatment of Hyperglycemia in DKD

R4 -- Intensive treatment of hyperglycemia in individuals with T1DM or T2DM IS RECOMMENDED for the prevention of DKD.

R5 -- Intensive control of hyperglycemia IS RECOMMENDED in individuals with DM to reduce albuminuria.

Treatment of hyperglycemia in Mild to Moderate DKD with GFR > 30 mL/min/1.73 m2

R6 -- In the treatment of T2DM and DKD with a GFR of 30-60 mL/min/1.73 m² or albuminuria >200 mg/g, the use of SGLT2 inhibitors is RECOMMENDED to reduce progression to end-stage renal disease and death.

R8 -- In T2DM patients with DKD and GFR > 30 mL/min/1.73 m 2 , the use of GLP-1 receptor agonists (GLP-1 RA) SHOULD BE CONSIDERED to reduce albuminuria.

R9 -- In individuals with T2DM and DKD with eGFR <30 mL/min/1.73 m² , with HbA1c above the target, insulin treatment SHOULD BE CONSIDERED as a priority to improve glycemic control.

R10 -- In patients with T2DM and DKD with a GFR of 15-30 mL/min/1.73 m² , and HbA1c above target, DPP-4 inhibitors, some sulfonylureas (glipizide and gliclazide) and GLP-1 RA MAY BE CONSIDERED to improve glycemic control. 

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