The 2020 Kidney Disease: Improving Global Outcomes Clinical Practice Guideline integrates new treatments and practices with existing management strategies for CKD patients with diabetes.
The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, published in mid-2020, is the first KDIGO guideline on the subject of CKD in the diabetes population.
The new guideline provides evidence-based best practices for care of patients with diabetes and CKD, including integrating new therapies with existing management strategies.
The full guideline is important reading for primary care clinicians. For a start, click through these 10 take-home points, from KDIGO.
Takeaway #1. Comprehensive care. Patients with diabetes and CKD have multisystem disease that requires treatment including a foundation of lifestyle intervention (healthy diet, exercise, no smoking) and pharmacologic risk factor management (glucose, lipids, blood pressure).
Takeaway #2. Nutrition in take. Patients should consume a balanced, healthy diet that is high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts; and lower in processed meats, refined carbohydrates, and sweetened beverages. Sodium (<2 g/day) and protein intake (0.8 g/kg/day) in accordance with recommendations for the general population.
Takeaway #3. Glycemic monitoring. It is advised to monitor glycemic control with A1c in patients with diabetes and CKD. For patients with advanced CKD (particularly those on dialysis), reliability of A1c decreases and results should be interpreted with caution. CGM or SMBG may also be useful, especially for treatment associated with risk of hypoglycemia.
Takeaway #4. Glycemic targets. Targets for glycemic control should be individualized ranging from <6.5% to <8.0%, taking into consideration risk factors for hypoglycemia, including advanced CKD and type of glucose-lowering therapy.
Takeaway #5. Sodium-glucose cotransporter-2 inhibitors. SGLT2i should be initiated for patients
with T2D and CKD when eGFR is ≥30 ml/min/1.73 m2 and can be continued after initiation at lower levels of eGFR. SGLT2i markedly reduce risks of CKD progression, heart failure, and atherosclerotic CV diseases, even when blood glucose is already controlled.
Takeaway #6. Metformin. Metformin should be used for patients with T2D and CKD when eGFR is ≥30 ml/min/1.73 m2. For such patients, metformin is a safe, effective, and inexpensive drug to control blood glucose and reduce diabetes complications.
Takeaway #7. Glucagon-like peptide1 receptor agonists. In patients with T2D and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2i, or who are unable to use those medications, a long-acting GLP-1 RA is recommended as part of the treatment.
Takeaway #8. Renin-angiotensin system blockade. Patients with T1D or T2D, hypertension, and albuminuria (persistent ACR >30 mg/g) should be treated with a RAS inhibitor (ACEi or ARB), titrated to the maximum approved or highest tolerated dose. Serum potassium and creatinine should be monitored.
Takeaway #9. Approaches to management. A team-based and integrated approach to manage patients with T2D and CKD should focus on regular assessment, control of multiple risk factors, and structured education in self-management to protect kidney function and reduce risk of complications.