New KDIGO guideline for management of diabetes in patients with CKD

Main recommendations are:

Comprehensive Care

1.We recommend that treatment with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) be initiated in patients with diabetes, hypertension, and albuminuria, and that these medications be titrated to the highest approved dose that is tolerated (1B).

2.We recommend advising patients with diabetes and CKD who use tobacco to quit using tobacco products (1D).

Glycemic Monitoring and Targets

4.We recommend an individualized HbA1c target ranging from <6.5% to <8.0% in patients with diabetes and CKD not treated with dialysis (1C).

Lifestyle Interventions

5.We suggest maintaining a protein intake of 0.8 g protein/kg (weight)/d for those with diabetes and CKD not treated with dialysis (2C).

6.We suggest that sodium intake be <2 g of sodium per day (or <90 mmol of sodium per day, or <5 g of sodium chloride per day) in patients with diabetes and CKD (2C).

7.We recommend that patients with diabetes and CKD be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with their cardiovascular and physical tolerance (1D).

Antihyperglycemic Therapies

8.We recommend treating patients with type 2 diabetes, CKD, and an eGFR ≥30 mL/min per 1.73 m2 with metformin (1B).

9.We recommend treating patients with type 2 diabetes, CKD, and an eGFR ≥30 mL/min per 1.73 m2 with an SGLT2i (1A).

10.In patients with type 2 diabetes and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2i, or who are unable to use those medications, we recommend a long-acting GLP-1 RA (1B).

Type 1 Diabetes

Studies evaluating new oral glucose-lowering medications added to different insulin regimens are sparse for patients with type 1 diabetes and CKD. Therefore, antihyperglycemic management in patients with type 1 diabetes should follow the recommendations of general diabetes guidelines.

Approachesto Management

1.We recommend that a structured self-management educational program be implemented for care of people with diabetes and CKD (1C).

2.We suggest that policymakers and institutional decision-makers implement team-based, integrated care focused on risk evaluation and patient empowerment to provide comprehensive care in patients with diabetes and CKD (2B).

Globally, more than 450 million persons have diabetes (>8%), with projected growth to more than 700 million by 2045.This first KDIGO guideline for management of diabetes in patients with CKD addresses several key issues relevant for clinical practice and highlights areas that merit further research.

The recommendations and practice points have direct relevance for clinicians, especially primary care physicians, nephrologists, cardiologists, and endocrinologists who care for most patients with diabetes and CKD.

Forfurther reference log on to:https://doi.org/10.7326/M20-5938