Top 10 Takeaways Clinicians - KDIGO
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Top 10 Takeaways for Clinicians from the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-creatinine ratio; ARB, angiotensin II receptor blocker; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HbA1c, hemoglobin A1c (glycated hemoglobin); RAS, renin-angiotensin system; SGLT2i, sodium-glucose cotransporter-2 inhibitor; SMBG, self-monitoring blood glucose; T1D, type 1 diabetes; T2D, type 2 diabetes All patients Most patients Lipid management Blood pressure control RAS blockade Glycemic control SGLT2 inhibitors Nutrition Some patients Diabetes with CKD Antiplatelet therapies Smoking cessation Exercise GLP-1 receptor agonist (preferred) DPP-4 inhibitor Insulin Sulfonylurea TZD Alpha-glucosidase inhibitor First-line therapy Lifestyle therapy Additional drug therapy as needed for glycemic control • Guided by patient preferences, comorbidities, eGFR, and cost • Includes patients with eGFR < 30 ml/min per 1.73 m 2 or treated with dialysis Physical activity Nutrition Weight loss SGLT2 inhibitor Metformin + Discontinue Discontinue Reduce dose Discontinue Do not initiate eGFR < 45 eGFR < 30 Dialysis Dialysis eGFR < 30 High risk ASCVD Potent glucose-lowering Avoid hypoglycemia Avoid injections Weight loss Low cost Heart failure eGFR < 15 mL/min/1.73 m 2 or treatment with dialysis GLP1RA GLP1RA, insulin GLP1RA, DPP4i, TZD, AGI DPP4i, TZD, SU, AGI, oral GLP1RA GLP1RA SU, TZD, AGI GLP1RA DPP4i, insulin, TZD DPP4i, TZD, AGI SU, insulin SU, AGI GLP1RA, insulin SU, insulin, TZD GLP1RA, DPP4i, insulin TZD M ore suita ble m e dicatio n s Less suitable m edications P r e f e r e n c e , c o m o r b id ity o r o t h e r c h a ra c t e r i s t i c Register Risk assessment Risk stratification Review Risk factor control Relay Reinforce Recall Treat to multiple targets (glycemia, BP, lipids) Use of organ-protective drugs (RASi, SGLT2i, GLP1RA, statins) Ongoing support to promote self-care Goals Uncoordinated care Coordinated care Empowered patients with optimal control Poorly-informed patients with suboptimal control 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). 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 sweet- ened beverages. Sodium (<2 g/day) and protein intake (0.8 g/kg/day) in accordance with recommendations for the general population. It is advised to monitor glycemic control with HbA1c in patients with diabetes and CKD. For patients with advanced CKD (particularly those on dialysis), reliability of HbA1c decreases and results should be interpreted with caution. CGM or SMBG may also be useful, especially for treatment associated with risk of hypoglycemia. 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. SGLT2i should be initiated for patients with T2D and CKD when eGFR is ≥30 ml/min/1.73 m 2 and can be continued after initiation at lower levels of eGFR. SGLT2i markedly reduce risks of CKD progression, heart failure, and atherosclerotic cardiovascular diseases, even when blood glucose is already controlled. Metformin should be used for patients with T2D and CKD when eGFR is ≥30 ml/min/1.73 m 2 . For such patients, metformin is a safe, effective, and inexpensive drug to control blood glucose and reduce diabetes compli- cations. 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 recommend- ed as part of the treatment. 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. A team-based and integrated approach to manage these patients 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. There is a paucity of data on optimal management of diabetes in kidney failure, including dialysis and transplantation, which should be a focus for future studies. 2 1 4 3 6 5 8 7 10 9 Comprehensive care Nutrition intake Glycemic monitoring Glycemic targets SGLT2i Metformin GLP-1 RA RAS blockade Approaches to management Research recommendations
Transcript of Top 10 Takeaways Clinicians - KDIGO
Top10
Takeaways for Clinicians from theKDIGO 2020 Clinical Practice Guidelinefor Diabetes Management in CKD
ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-creatinine ratio; ARB, angiotensin II receptor blocker; CKD, chronic kidney disease; eGFR, estimated glomerular �ltration rate; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HbA1c, hemoglobin A1c (glycated hemoglobin); RAS, renin-angiotensin system; SGLT2i, sodium-glucose cotransporter-2 inhibitor; SMBG, self-monitoring blood glucose; T1D, type 1 diabetes; T2D, type 2 diabetes
Allpatients
Mostpatients
Lipidmanagement
Bloodpressurecontrol
RASblockade
Glycemiccontrol
SGLT2inhibitors
Nutrition
Somepatients
Diabetes with CKD
Antiplatelettherapies
Smoking cessationExercise
GLP-1 receptor agonist(preferred)
DPP-4 inhibitor Insulin
Sulfonylurea TZD
Alpha-glucosidase inhibitor
First-linetherapy
Lifestyle therapy
Additional drug therapy asneeded for glycemic control
• Guided by patient preferences, comorbidities, eGFR, and cost• Includes patients with eGFR < 30 ml/min per 1.73 m2
or treated with dialysis
Physical activityNutrition
Weight loss
SGLT2 inhibitorMetformin
+
DiscontinueDiscontinueReduce dose DiscontinueDo not initiate
eGFR< 45
eGFR< 30
Dialysis DialysiseGFR< 30
High riskASCVD
Potentglucose-lowering
Avoidhypoglycemia
Avoidinjections
Weightloss
Low cost
Heartfailure
eGFR < 15mL/min/1.73
m2 or treatmentwith dialysis
GLP1RA
GLP1RA,insulin
GLP1RA,DPP4i,
TZD, AGI
DPP4i, TZD, SU, AGI,oral GLP1RA
GLP1RA
SU, TZD,AGI
GLP1RA
DPP4i,insulin,
TZD
DPP4i,TZD, AGI
SU,insulin
SU, AGI
GLP1RA, insulinSU, insulin, TZD
GLP1RA,DPP4i,insulin
TZD
More suitable medications
Less suitable medicationsPr
efer
ence, comorbidity or other characteristic
RegisterRisk assessment
Riskstrati�cation
ReviewRisk factor
control
RelayReinforce
Recall
Treat to multiple targets(glycemia, BP, lipids)Use of organ-protective drugs(RASi, SGLT2i, GLP1RA, statins)Ongoing support to promoteself-care
Goals
Uncoordinated care Coordinated care
Empowered patientswith optimal control
Poorly-informed patientswith suboptimal control
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).
Patients should consume a balanced, healthy diet that is high in vegetables, fruits, whole grains, �ber, legumes, plant-based proteins, unsaturated fats, and nuts; and lower in processed meats, re�ned carbohydrates, and sweet-ened beverages. Sodium (<2 g/day) and protein intake (0.8 g/kg/day) in accordance with recommendations for the general population.
It is advised to monitor glycemic control with HbA1c in patients with diabetes and CKD. For patients with advanced CKD (particularly those on dialysis), reliability of HbA1c decreases and results should be interpreted with caution. CGM or SMBG may also be useful, especially for treatment associated with risk of hypoglycemia.
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.
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 cardiovascular diseases, even when blood glucose is already controlled.
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 compli-cations.
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 recommend-ed as part of the treatment.
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.
A team-based and integrated approach to manage these patients 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.
There is a paucity of data on optimal management of diabetes in kidney failure, including dialysis and transplantation, which should be a focus for future studies.
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Comprehensive care
Nutrition intake
Glycemic monitoring
Glycemic targets
SGLT2i
Metformin
GLP-1 RA
RAS blockade
Approaches to management
Research recommendations
