Aggressive management in stage 3 CKD preserves kidney function in diabetes
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Adults with type 2 diabetes and a low estimated glomerular filtration rate must be more aggressively managed with tailored treatment options to preserve kidney function and reduce morbidity and mortality risk.
Individuals with an eGFR of less than 60 mL/min/1.73m² — and even those with an eGFR of less than 45 mL/min/1.73m² — who have albuminuria should not stop taking renin-angiotensin-aldosterone system (RAAS) inhibitors, such as ACE inhibitors, if their creatinine level goes up as much as 30%, unless the person has hyperkalemia, George L. Bakris, MD, professor of medicine and director of the American Heart Association Comprehensive Hypertension Center at the University of Chicago Medicine, said during a presentation at the American Diabetes Association Scientific Sessions. Glycemic management in chronic kidney disease is important and there are some diabetes agents that cannot be used; however, SGLT2 inhibitors have renal effects that are independent of glycemic control and can be used safely even in the setting of a low eGFR, he said.
“A rise in serum creatinine of up to 30% within a week of initiating blood pressure control, regardless of whether a blocker of the renin angiotensin system is used, should be tolerated in the absence of hyperkalemia,” Bakris told Healio. “There are multiple studies showing benefit on renal and CV outcomes. Clinicians should be careful, as there are only two sulfonylurea agents that are not renally handled, glimepiride and glipizide, and these are preferred to reduce the risk of hypoglycemia.”
Bakris said clinicians must also always check albumin to creatinine ratio to ensure proper staging of CKD. A ratio between 30 and 300 with an eGFR of at least 60 mL/min/1.73m² is not kidney disease, Bakris said, but the individual is still at high CV risk, as high albuminuria is an inflammatory marker.
“Once a year is fine, but you do have to measure it," Bakris said. “Many people think, for microalbuminuria, give the person an ACE inhibitor, send them home and it’s fine. Nothing could be further from the truth. You need to think of microalbuminuria as the kidney’s C-reactive protein level. It is a marker of inflammation. If all you’re going to do is throw an ACE inhibitor at it, you are masking it and you could miss something that is very treatable.”
Bakris said clinicians should consider several important points in stage 3 CKD management in the setting of type 2 diabetes:
- Guidelines mandate the use of ACE inhibitors or angiotensin receptor blockers in people with advanced CKD, defined as an eGFR of less than 60 mL/min/1.73m², and albuminuria of at least 300 mg/dL, to slow nephropathy progression;
- A rise in serum creatinine of up to 30% from baseline with no hyperkalemia should be maintained, especially if blood pressure is in the range of 130/80 mm Hg;
- Clinicians should consider use of a daily potassium binder if a RAAS inhibitor is indicated and hyperkalemia prevents its use;
- Stopping RAAS inhibitors for perceived safety reasons fails to protect the kidney and increases CV risk; and
- SGLT2 inhibitors can be used safely for people with an eGFR as low as 30 mL/min/1.73m² for primarily cardiorenal protection, and not glycemic response.
“The bottom line is this approach is to reduce cardiorenal risk for morbid events,” Bakris said.
In a question-and-answer session after the presentation, Bakris addressed the use of SGLT2 inhibitors specifically for renal protection among people with type 2 diabetes and a mildly reduced eGFR between 70 and 80 mL/min/1.73m², considered stage 2 CKD.
“The reality is that the earlier you intervene, the better off you will be,” Bakris said. “I mention an eGFR of between 60 and 40 mL/min/1.73m² because people say that this is a glucose drug. Keep in mind, however, a person’s age. If a patient is aged 60 years and has an eGFR of 65 or 70 mL/min/1.73m², absolutely I would use an SGLT2 inhibitor. If a patient is aged 30 years and has an eGFR of 90 mL/min/1.73m², I would probably want to do other things first.”
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Bakris GL. Tailoring treatment options based on diabetes comorbidities: Patients with low estimated glomerular filtration rate. Presented at: American Diabetes Association Scientific Sessions; June 12-16, 2020 (virtual meeting).
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