Representatives from the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) organization have issued a consensus report on treating diabetes in chronic kidney disease (CKD) based on shared recommendations from their respective evidence-based guidelines.

“With multiple interventions ubiquitously needed to optimize the care of people with diabetes and CKD, it is crucial to avoid therapeutic inertia,” Ian H. de Boer, MD, MS, of the Kidney Research Institute at the University of Washington in Seattle and colleagues stated in Kidney International.

According to the joint committee:

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• All patients with type 1 diabetes (T1D) or type 2 diabetes (T2D) and CKD should receive a comprehensive plan to optimize nutrition, exercise, smoking cessation, and weight, as a foundation for any pharmacotherapy.

• In patients with T1D or T2D who have hypertension and albuminuria, work towards maximally tolerated ACE inhibitor (ACEi) or angiotensin II receptor blocker (ARB) use.

• Initiate statin therapy in all patients with T1D or T2D and CKD, including moderate intensity for primary prevention and high-intensity for secondary prevention of atherosclerotic cardiovascular disease (ASCVD).

• Consider metformin for patients with T2D, CKD, and an estimated glomerular filtration rate (eGFR) of at least 30 mL/min/1.73 m2. Reduce the dose for those at high risk of lactic acidosis.

• Initiate a sodium-glucose cotransporter-2 inhibitor (SGLT2i) in patients with T2D, CKD, and an eGFR of at least 20 mL/min/1.73 m2. Once initiated, the SGLT2i can be continued at lower levels of eGFR, according to the committee.

• Use a glucagon-like peptide 1 (GLP-1) receptor agonist for patients with T2D and CKD who do not meet their individualized glycemic target with metformin and/or an SGLT2i.

• Consider prescribing a nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) with proven kidney and cardiovascular benefit in patients with T2D, an eGFR of at least 25 mL/min/1.73 m2, normal serum potassium, and albuminuria despite optimized treatment with a renin-angiotensin system (RAS) inhibitor.

The joint committee also discussed individualizing treatment targets, additional glucose-lowering agents, weighing the risks, benefits, and costs of agents, and dose adjustment for treating diabetes in chronic kidney disease.

“Clinical practice guidelines will continue to evolve,” the joint committee wrote. “When possible, consensus approaches to diagnosis and management will help interpret new data in context and translate discoveries to improved outcomes for patients.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

Reference

de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. Published online September 27, 2022. doi:10.1016/j.kint.2022.08.012

Topics:

Chronic Kidney Disease Diabetes Diabetic Nephropathy Hyperglycemia Medications