Diabetes management in patients with CKD: Key takeaways from ADA and KDIGO guidance
USA: The American Diabetes Association (ADA) and the Kidney Disease: Improving Global Outcomes (KDIGO) organization have released joint guidance on how to manage patients with diabetes and chronic kidney disease (CKD).
The new consensus report has been published online October 3 in Diabetes Care and Kidney International.
Patients with diabetes and chronic kidney disease (CKD) are at increased risk for heart failure, atherosclerotic cardiovascular disease, kidney failure, and premature mortality. Recent clinical trials support new approaches for treating CKD and diabetes. The 2022 ADA and the KDIGO each provides evidence-based recommendation for diabetes management in chronic kidney disease.
A series of consensus statements were reviewed and developed by a joint group of ADA and KDIGO representatives to guide clinical care from the ADA and KDIGO guidelines. Recommendations include comprehensive care in which pharmacotherapy is layered on a foundation of a healthy lifestyle. Consensus statements issue specific guidance in the use of metformin, renin-angiotensin system inhibitors, sodium-glucose cotransporter-2 inhibitors, a nonsteroidal mineralocorticoid receptor antagonist, and glucagon-like peptide 1 receptor agonists. These areas of consensus provide clear direction for the implementation of care for improving clinical outcomes of patients with diabetes and CKD.
ADS/KDIGO Consensus Statement is given below
- The authors recommend an ACE inhibitor (ACEi) or angiotensin II receptor blocker (ARB) for patients with type 1 diabetes or type 2 diabetes who have hypertension and albuminuria, titrated to the maximum antihypertensive or highest tolerated dose.
- All patients with type 1 diabetes or type 2 diabetes and CKD should be treated with a comprehensive plan, outlined and agreed by health care professionals and the patient together, to optimize nutrition, exercise, smoking cessation, and weight, upon which are layered evidence-based pharmacologic therapies aimed at preserving organ function and other therapies selected to attain intermediate targets for glycemia, blood pressure (BP), and lipids.
- Metformin is recommended for patients with T2D, CKD, and estimated glomerular filtration rate (eGFR) ≥30 ml/min/1.73 m2; the dose should be reduced to 1000 mg daily in patients with eGFR of 30–44 ml/min/1.73 m2 and in some patients with eGFR 45–59 ml/min/1.73 m2 who are at high risk of lactic acidosis.
- A statin is recommended for all patients with T1D or T2D and CKD, moderate intensity for primary prevention of atherosclerotic cardiovascular disease (ASCVD), or high intensity for patients with known ASCVD and some patients with multiple ASCVD risk factors.
- The authors recommend a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit for patients with T2D and CKD who do not meet their individualized glycemic target with metformin and/or an SGLT2i or who are unable to use these drugs.
- The authors recommend a sodium-glucose cotransporter-2 inhibitor (SGLT2i) with proven kidney or cardiovascular benefit for patients with T2D, CKD, and eGFR ≥20 ml/min/1.73 m2. Once initiated, the SGLT2i can be continued at lower levels of eGFR.
- The authors recommend a nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) with proven kidney and cardiovascular benefits for patients with T2D, eGFR ≥25 ml/min/1.73 m2, normal serum potassium concentration, and albuminuria (albumin-to-creatinine ratio [ACR] ≥30 mg/g) despite maximum tolerated dose of renin-angiotensin system (RAS) inhibitor.
Reference:
de Boer IH, Khunti K, Sadusky T, Tuttle KR, Neumiller JJ, Rhee CM, Rosas SE, Rossing P, Bakris G. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022 Oct 3:dci220027. doi: 10.2337/dci22-0027. Epub ahead of print. PMID: 36189689.
