The Kidney Disease Improving Global Outcomes (KDIGO) organization has issued its first clinical practice guideline for management of type 1 or 2 diabetes in patients with chronic kidney disease (CKD), including those on dialysis and who have received kidney transplants. In the latest issue of the Annals of Internal Medicine, Kamlesh Khunti, MD, PhD, of Leicester Diabetes Centre, Leicester General Hospital in Leicester, United Kingdom, and colleagues offered a synopsis of the guideline’s key points.
The full KDIGO guideline comprises 5 chapters addressing comprehensive care needs, glycemic monitoring and targets, lifestyle interventions, antihyperglycemic therapies, and educational and integrated care approaches for patients with diabetic kidney disease. The KDIGO Work Group used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to appraise evidence and rate the strength of the 12 recommendations described here (in italics, as they appear in the guideline). Experts also supplied 48 consensus practice points where evidence was lacking (ie, advice that previously might have been considered Grade 2D) in the full guideline and listed in the synopsis.
We recommend that treatment with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) be initiated in patients with diabetes, hypertension, and albuminuria, and that these medications be titrated to the highest approved dose that is tolerated (Grade 1B).
Patients with diabetes, hypertension, and albuminuria should receive renin-angiotensin system (RAS) inhibitors, titrated to the maximal tolerated dose, with close monitoring of serum potassium and serum creatinine levels. If hyperkalemia occurs, clinicians can consider moderating potassium intake, initiating a diuretic, using sodium bicarbonate in patients with metabolic acidosis, and starting concomitant use of gastrointestinal cation exchangers.
Avoid using ACEis and ARBs together because the combination is harmful, the reviewers noted. Mineralocorticoid receptor antagonists (MRA), such as spironolactone and eplerenone, are effective for resistant hypertension. Additionally, the recent FIDELIO trial found that finerenone, a selective nonsteroidal MRA, resulted in lower risks for CKD progression and cardiovascular events in patients with diabetic kidney disease taking RAS inhibitors.
We recommend advising patients with diabetes and CKD who use tobacco to quit using tobacco products (Grade 1D).
Glycemic Monitoring and Targets
We recommend using hemoglobin A1c (HbA1c) to monitor glycemic control in patients with diabetes and CKD (1C).
The guideline acknowledges that once estimated glomerular filtration rate (eGFR) declines to 30 mL/min/1.73 m2, and especially to less than 15 mL/min/1.73 m2, HbA1c less accurately reflects blood glucose levels (due to shortened erythrocyte lifespan). Continuous glucose monitoring (CGM) is one of the mentioned alternatives.
We recommend an individualized HbA1c target ranging from <6.5% to <8.0% in patients with diabetes and CKD not treated with dialysis (1C).
Figure 9 in the full guideline outlines factors guiding decisions on individual HbA1c targets. A target of less than 8.0% may be appropriate for a patient with stage 5 CKD, macrovascular complications, and high propensity of treatment to cause hypoglycemia.
We suggest maintaining a protein intake of 0.8 g protein/kg (weight)/d for those with diabetes and CKD not treated with dialysis (2C).
The guideline states that a daily protein intake of 0.8 g protein/kgdaily is the level recommended by the World Health Organization for the general population. Patients receiving dialysis, particularly peritoneal dialysis, can increase daily dietary protein intake to 1.0 to 1.2 g/kg to offset catabolism and negative nitrogen balance.
We suggest that sodium intake be <2 g of sodium per day (or <90 mmol of sodium per day, or <5 g of sodium chloride per day) in patients with diabetes and CKD (2C).
According to the reviewers, this sodium limit is consistent with the upcoming KDIGO guideline on blood pressure management in CKD and international guidelines on the prevention and treatment of cardiovascular disease.
We recommend that patients with diabetes and CKD be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with their cardiovascular and physical tolerance (1D).
We recommend treating patients with type 2 diabetes, CKD, and an eGFR ≥30 mL/min/1.73 m2 with metformin (1B).
We recommend treating patients with type 2 diabetes, CKD, and an eGFR ≥30 mL/min/1.73 m2 with an SGLT2i (1A).
In patients with type 2 diabetes and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2i, or who are unable to use those medications, we recommend a long-acting GLP-1 RA (1B).
Glycemic management for patients with type 2 diabetes and CKD should include lifestyle therapy, then first-line treatment with both metformin and a sodium-glucose cotransporter-2 (SGLT2) inhibitor for most patients with an eGFR at or above 30 mL/min per 1.73 m2, followed by additional drug therapy as needed (glucagon-like peptide-1 receptor agonists [GLP-1 RAs] are generally preferred).
Approaches to Management
We recommend that a structured self-management educational program be implemented for care of people with diabetes and CKD (1C).
We suggest that policymakers and institutional decision-makers implement team-based, integrated care focused on risk evaluation and patient empowerment to provide comprehensive care in patients with diabetes and CKD (2B).
The KDIGO guideline is valuable for nephrologists, Dr Khunti and colleagues stated, as well as primary care physicians, endocrinologists, cardiologists, diabetes nurse educators, pharmacists, dietitians or nutritionists, and other clinicians caring for patients with diabetes and CKD. A team-based, integrated approach enables regular assessment, control of multiple risk factors, and self-management to protect kidney function and reduce risk for complications.
Disclosure: No funding was accepted for guideline creation. Please see the original reference for a full list of reviewer and authors’ disclosures.
Navaneethan SD, Zoungas S, Caramori ML, et al. Diabetes management in chronic kidney disease: Synopsis of the 2020 KDIGO clinical practice guideline. Ann Intern Med. doi:10.7326/M20-5938
Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. Kidney Disease: Improving Global Outcomes (KDIGO) 2020 clinical practice guideline for diabetes management in chronic kidney disease (CKD).