Organizations release consensus report on managing patients with diabetic kidney disease

The American Diabetes Association and Kidney Disease: Improving Global Outcomes have released a consensus report addressing diabetes management in chronic kidney disease.

“It is compelling that we now have a general agreement between diabetologists and nephrologists on how to diagnose and treat diabetic kidney disease in its early stages to markedly delay progression,” George Bakris, MD, report co-author and director of the Comprehensive Hypertension Center at University of Chicago, said in a press release. “This is a message for primary care physicians, and like any report, it should be translated by the caregiver to the patient so that both parties can agree on a common approach.”

A joint writing group of the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) reviewed and developed a series of consensus statements that provide direction for the implementation of care to improve clinical outcomes for patients with diabetes and CKD. The organizations aligned in areas of CKD screening and diagnosis, glycemia monitoring, lifestyle therapies, treatment goals and pharmacologic management, according to the release.

“This report is all the more compelling given the recent advances in the field and dramatic public health toll that CKD poses,” Robert Gabbay, MD, PhD, chief scientific and medical officer of the ADA, said in the release.

Specific recommendations in the consensus report, written by Ian H. de Boer, MD, and colleagues, and published jointly in Kidney International and Diabetes Care, include the following:

• All patients with type 1 diabetes (T1D) or type 2 diabetes (T2D) 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.
• Evidence-based pharmacologic therapies aimed at preserving organ function and other therapies selected to attain intermediate targets for glycemia, blood pressure and lipids should also be included.
• The consensus report recommends an ACE inhibitor or angiotensin II receptor blocker for patients with T1D or T2D who have hypertension and albuminuria.
• A statin is recommended for all patients with T1D or T2D and CKD.
• Metformin is recommended for patients with T2D, CKD, and an eGFR of 30 mL/min/1.73 m² or greater; the dose should be reduced to 1,000 mg daily in patients with eGFR between 30 mL/min/1.73 m² and 44 mL/min/1.73 m² and in some patients with eGFR of 45 mL/min/1.73 m² to 59 mL/min/1.73 m² who are at high risk of lactic acidosis.
• A sodium-glucose cotransporter 2 inhibitor (SGLT2i) with proven kidney or cardiovascular benefit is recommended for patients with T2D, CKD and an eGFR of 20 mL/min/1.73 m² or greater.
• Once initiated, the SGLT2i can be continued at lower levels of eGFR.
• A glucagon-like peptide 1 receptor agonist with proven cardiovascular benefit is recommended 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, according to the census report.
• A nonsteroidal mineralocorticoid receptor antagonist with proven kidney and cardiovascular benefit is recommended for patients with T2D, an eGFR of 25 mL/min/1.73 m² or greater, normal serum potassium concentration and albuminuria (albumin-to-creatinine ratio greater than or equal to 30 mg/g) despite maximum tolerated dose of renin-angiotensin system inhibitor, the authors wrote.

References:

• 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;doi:10.2337/dci22-0027.
• The American Diabetes Association and Kidney Disease: Improving Global Outcomes release a consensus report on diabetes management in chronic kidney disease. https://kdigo.org/news-release-ada-kdigo-release-joint-consensus-report-on-diabetes-management-in-ckd/. Published Oct. 4, 2022. Accessed Oct. 5, 2022.

Editors Note: The article was updated on October 13, 2022, to correct a typo. The Editors regret the error.