medwireNews: The ADA and KDIGO have produced a consensus statement on treating chronic kidney disease (CKD) in people with diabetes.
Presenting the groups’ conclusions at the 82nd ADA Scientific Sessions in New Orleans, Louisiana, Peter Rossing (Steno Diabetes Center Copenhagen, Denmark) explained that representatives of both organizations came together to compare their existing guidelines and identify areas of agreement and divergence.
Overall, he said, the two guidelines were in strong agreement: “We are really speaking the same language.”
The consensus statement covers screening and diagnosis, comprehensive care, and treatment targets and pharmacotherapy.
Screening should occur annually from the point of diabetes in people with type 2 diabetes and from 5 years after diagnosis in those with type 1 diabetes, with only persistent abnormalities defining CKD.
Rossing stressed the need to screen for both estimated glomerular filtration rate (eGFR) and urinary albumin to creatinine ratio, pointing to data showing that the former, but not the latter, is regularly assessed. And he noted that, besides being diagnostic, these two parameters can also help physicians to determine renal and cardiovascular risk, frequency of follow-up, and when to refer to specialist care.
The statement includes a treatment algorithm, based on promoting a healthy lifestyle, followed by escalating medication options.
First-line medication for all CKD patients, including those with type 1 diabetes, are renin–angiotensin system inhibitors and moderate- or high-intensity statins. Additional options for people with type 2 diabetes are sodium-glucose cotransporter (SGLT)2 inhibitors and metformin.
Rossing noted that metformin can be given to people with an eGFR of at least 30 mL/min per 1.73 m2 and, based on the most recent data, SGLT2 inhibitors can be started down to an eGFR of 20 mL/min per 1.73 m2 and continued even if it subsequently falls lower.
He observed that despite the currently high upfront costs of SGLT2 inhibitors, early analysis suggests that they are actually cost-saving from an overall healthcare perspective, and also improve quality of life, which he described as “a rather unique position for new treatments” and down to their ability to delay or prevent dialysis and transplantation.
After these first-line options come additional therapies for optimizing glucose levels and minimizing renal risk. Rossing highlighted the recommendation for glucagon-like peptide-1 receptor agonists in people with type 2 diabetes, because of their strong cardioprotective effects, and the option of a nonsteroidal mineralocorticoid receptor antagonist (ie, finerenone), also for people with type 2 diabetes if they have residual renal risk.
The presenter added that glycated hemoglobin (HbA1c) targets in people with CKD should be individualized, within a range of 6.5% to 8.0% (48 to 64 mmol/L), according to factors including CKD severity, macrovascular complications, life expectancy, and hypoglycemia risk.
But he noted that HbA1c in CKD patients is “not always very precise,” and the guidelines therefore recommend use of continuous glucose monitoring to aid glycemic control in this population. The statement also provides guidance on which glucose-lowering agents require dose adjustment in people whose eGFR falls below 45 mL/min per 1.73 m2.
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