Recommendations aim to help clinicians apply evidence to practice, expert says

The international Kidney Disease: Improving Global Outcomes (KDIGO) issued its first guideline for diabetes management in chronic kidney disease (CKD) and offered “evidence-based recommendations and practice points to optimize the clinical care of people with diabetes and CKD by integrating new therapies with existing management approaches.”

The guideline covers all patients with diabetes (type 1 and type 2), and all severities of CKD, including patients treated with dialysis or who have undergone a kidney transplant, explained Sankar D. Navaneethan, MD, MS, MPH, of the Baylor College of Medicine and Michael E. DeBakey VA Medical Center, both in Houston, and co-authors in the KDIGO work group.

The guideline has a dozen recommendations and 48 practice points, they wrote in a synopsis in the Annals of Internal Medicine, and it focuses on these key issues:

  • Comprehensive care needs.
  • Glycemic monitoring and targets.
  • Lifestyle interventions.
  • Anti-hyperglycemic therapies.
  • Educational and integrated care approaches.

“The guideline comes at a pivotal time, with substantial growth in the public health burden of diabetes and [CKD], and with recent development of new therapies applicable to this population,” wrote working group co-chair Ian H. de Boer, MD, MS, of the Kidney Research Institute at the University of Washington in Seattle, and co-authors in an executive summary in Kidney International.

“We also wanted to be rigorous and evidence-based, so we wanted to deal with areas that had randomized, controlled trial data to give us a solid backing for the recommendation,” noted de Boer in a KDIGO video. “We also wanted to be practical.”

“It’s the first time that KDIGO has decided to bring in the patient perspective,” added KDIGO working group member and patient advocate Tami Sudusky, MBA, MS, of the Kidney Research Institute in Seattle.

Recommendations from the guideline include:

  • Comprehensive care: Use either angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers when appropriate at the highest approved dose tolerated.
  • Glycemic monitoring and targets: An individualized hemoglobin A1c target ranging from <6.5% to <8.0% in patients with diabetes and CKD who are not on dialysis.
  • Lifestyle: Diet high in vegetables, fruits, and whole grains; protein intake of 0.8 g protein/kg (weight)/day for non-dialysis patients; moderate intensity physical activity for at least 150 minutes/week.
  • Anti-hyperglycemic therapies: Glycemic management for patients with type 2 diabetes and CKD should include lifestyle therapy, first-line treatment with metformin and a sodium-glucose cotransporter-2 inhibitor (SGLT2i), plus as-needed additional drug therapy for glycemic control.
  • Educational and integrated care approaches: “We suggest… team-based, integrated care focused on risk evaluation and patient empowerment to provide comprehensive care in patients with diabetes and CKD.”

For glycemic monitoring, Navaneethan and co-authors noted that “Continuous glucose monitoring (CGM) is an alternative approach to glucose monitoring that is not affected by CKD. Continuous glucose monitoring or self-monitoring of blood glucose may be particularly useful among patients in whom HbA1c is not concordant with directly measured blood glucose levels or clinical symptoms.” There are currently four FDA-approved CGM systems on the market, and many more approved globally. The world-wide CGM market was valued at $1,7 million in 2019 and is projected to reach over $8 million by 2027, according to Valuates Reports.

Also part of comprehensive care is encouraging patients to quit tobacco products, according to de Boer and co-authors in the executive summary, calling the potential harm of smoking “compelling.” Navaneethan’s group pointed out that “Few studies have examined the potential benefits of smoking cessation in patients with diabetes and CKD. However, given the known health and economic benefits of avoiding tobacco products in the general population, the guideline suggests that health care providers recommend tobacco cessation.”

As for the use of blood pressure (BP) medications in these patients, de Boer’s group explained that “CKD often leads to sodium retention, which increases blood pressure, and risks of CKD progression and cardiovascular events.” As a result, the KDIGO work group proposed keeping sodium intake to <2 g/d (or <5 g sodium chloride), which are in line with the KDIGO guideline on BP management and World Health Organization guidelines on the prevention and treatment of CVD.

And for anti-hyperglycemic therapies, the authors noted that if metformin and SGLT2i are not options, then “GLP-1 RA are preferred additional agents because of their demonstrated beneficial effects to reduce cardiovascular events, particularly among people with prevalent atherosclerotic CVD, and also their potential to prevent onset of severely increased albuminuria (formerly known as macroalbuminuria) and possibly slow decline in [estimated glomerular filtration rate].”

In the video, de Boer stressed that the working group was geographically diverse as “diabetes is the most important cause of [CKD], around the world. Care practices change, and are different across the world, so we wanted to make sure our guideline had some relevance to people in all parts of the world.”

The KDIGO guideline joins offerings from other groups: In 2019, the American Diabetes Association updated its recommendations with data from the CREDENCE trial, while in 2020, The Endocrine Society published a review on glycemic monitoring and management in CKD.

A webinar on the guideline and a meet-the-experts session is available on the KDIGO website.

  1. The new Kidney Disease: Improving Global Outcomes (KDIGO) guideline includes 12 recommendations and 48 practice points for clinicians caring for patients with diabetes and chronic kidney disease (CKD).

  2. Key recommendations cover comprehensive care needs, glycemic monitoring and targets, lifestyle interventions, antihyperglycemic therapies, and educational and integrated care approaches.

Shalmali Pal, Contributing Writer, BreakingMED™

Navaneethan reported relationships with Bayer, Boehringer Ingelheim, Reata, and Tricida, as well as support from Keryx. Co-authors reported relationships with, and/or support from, AstraZeneca, Boehringer Ingelheim, Merck Sharp & Dohme Australia, Novo Nordisk, Sanofi, Servier Laboratories Australia, Eli Lilly Australia, Bayer, Gilead, Novartis, Asia Diabetes Foundation, Merck Sharp & Dohme, Hua Medicine, Lee Powder, Pfizer, GEMVCARE, AbbVie, CSL Pharma, Chinook, Janssen, Mitsubishi Tanabe, Retrophin, Alnylam, Davita, George Clinical, Baxter, the Global Alliance for Chronic Diseases-Indian Council of Medical Research, Government of India, the Indian Council of Medical Research, National Heart, Lung, and Blood Institute, Goldfinch Bio, Mundipharma, GlaxoSmithKline, Fresenius Medical Care, Vifor Fresenius Care Renal Pharma, Tricida, Akibia, B. Braun, Shire-Takeda, Sanofi-Genzyme, Daiichi Sankyo, Astellas, and a start-up biogenetic testing company with partial support from the Hong Kong government.

de Boer reported relationships with, and/or support from, Boehringer Ingelheim, Cyclerion Therapeutics, George Clinical, Goldfinch Bio, Ironwood, Abbott, and Medtronic. Sudusky reported no relationships relevant to the contents of this paper to disclose.

Cat ID: 12

Topic ID: 76,12,12,187,127,192,918,925