The Kidney Disease: Improving Global Outcomes (KDIGO) Work Group has published the KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease (CKD) in the Annals of Internal Medicine.¹ The new updated guidelines recommend adoption of a “layered approach” to managing diabetes patients with CKD.

Lifestyle interventions consisting of healthy diet, physical activity, smoking cessation and weight control form the base of the treatment pyramid. To this are added the first-line drugs. The subsequent layers of “risk-based therapy” include additional drugs with cardiorenal protective effects to reduce risk of CVD events and progression of kidney disease and controlling risk factors like blood pressure, hyperglycemia and dyslipidemia. “The KDIGO layered approach includes the preference for starting new treatments one at a time and then reassessing response and residual risk to further refine therapy.”

The preferred first-line drugs for all patients with T2DM and CKD with an eGFR of at least 20 mL/min/1.73 m2 are SGLT2 inhibitors. If eGFR is ≥30 mL/min/1.73 m2, metformin may be given. In patients with diabetes, hypertension and albuminuria, renin-angiotensin system (RAS) inhibition with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) is recommended.

For patient with T2DM at high risk of CKD progression as evident by an eGFR ≥25 ml/min per 1.73 m2, normal serum potassium and albuminuria (≥30 mg/g [≥3 mg/mmol]) despite maximum tolerated dose of RAS inhibitor, a nonsteroidal mineralocorticoid receptor antagonist (nsMRA) such as finerenone can be used as a first-line option.

GLP-1 RAs remain the second-line choice for glucose-lowering in patients with type 2 diabetes and CKD, particularly those who are overweight or obese or those who have not achieved optimal glycemic targets despite the use of SGLT2 inhibitors and metformin or are intolerant to SGLT2 inhibitors or metformin. In patients with known CVD, aspirin is recommended for secondary prevention. In patients at high risk for ASCVD, use of aspirin for primary prevention may be considered.

Patients should be regularly evaluated, including for risk factors, every 3-6 months to optimize therapy.

Other key recommendations include tobacco cessation, use of HbA1c to monitor glycemic control with target A1c of <6.5% to <8.0% in non-dialysis patients, protein intake of 0.8 g protein/kg (weight)/day for non-dialysis patients, daily intake of less than 5 g of salt and moderate-intensity physical activity for at least 150 minutes per week. The Working Group further recommends “a structured self-management educational program” for patients with diabetes and CKD.

Reference

1. Navaneethan SD, et al. Diabetes management in chronic kidney disease: Synopsis of the KDIGO 2022 Clinical Practice Guideline Update. Ann Intern Med. 2023 Jan 10. doi: 10.7326/M22-2904.