Consensus- New Joint Statement from ADA and KDIGO on Management of Diabetes and CKD

Prof. Peter Rossing, Julio A. Lamprea-Montealegre

The American Diabetes Association (ADA)/ Kidney Disease Improving Global Outcomes (KDIGO) consensus statement on the management of diabetes and chronic kidney disease (CKD) covers screening and diagnosis strategies, treatments, targets for pharmacotherapy and the need for comprehensive care.

Screen for kidney disease with eGFR and albuminuria

Screening is the foundation for the diagnosis and treatment of kidney disease. Around 90% of the patients have a yearly screening of eGFR, but only approximately 50% are screened for albuminuria. The consensus recommends regular screening for albuminuria and estimated glomerular filtration rate (eGFR). As per Prof. Peter Rossing, “The more you look for kidney disease, the more you will find. And if you don't look, you will not find it and then you will not treat it”. The combination of albuminuria and eGFR can also be used to assess risk for kidney failure, cardiovascular events, and morbidity and mortality. It can also help assess if the patient needs referral to specialized care such as a nephrologist.

Healthy lifestyle and education - The foundation

A holistic approach should be followed for improving outcomes in patients with type 2 diabetes and CKD. The foundation is a healthy lifestyle with a healthy diet, physical activity, stopping smoking, and then managing weight in those that are obese.

Pharmacotherapy - First-line therapy includes SGLT2i, renin-angiotensin system inhibitor, metformin, and statins

Sodium-glucose cotransporter 2 (SGLT2) inhibitor should be the first-line therapy in people with diabetes and CKD. An SGLT2i with proven kidney or cardiovascular benefits is recommended for patients with T2D, CKD, and an eGFR≥20 mL/min/1.73 m². Once initiated, the SGLT2i can be continued at lower levels of eGFR. Concurrent first-line treatment includes renin-angiotensin system inhibitor (an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker), metformin, and a statin. Glucagon-like peptide-1 (GLP-1) receptor agonist can be added in patients who need additional glycemic control on top of metformin and an SGLT2 inhibitor. Finerenone, the non-steroidal mineralocorticoid receptor antagonist, is recommended in type 2 diabetes with residual kidney and cardiovascular disease.

Overcoming barriers to management of CKD in patients with diabetes

There are several barriers to address when managing people with diabetes and CKD. Organization of care is key to overcoming barriers to implementation and treatment inertia. Education of health care professionals, harmonization of clinical practice guidelines, self-management programs, and multidisciplinary care models are key when managing people with diabetes and CKD.

Reference

Prof. Peter Rossing. Consensus- New Joint Statement from ADA and KDIGO on Management of Diabetes and CKD. Symposium at: American Diabetes Association 82nd Scientific Sessions; June, 2022.