Practice Guidelines

Chronic Kidney Disease in Diabetes: Guidelines from KDIGO

 

Am Fam Physician. 2021 Jun 1;103(11):698-700.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Structured diabetes self-management education programs are recommended because they improve self-efficacy and clinical outcomes.

• First-line antiglycemic treatment for type 2 diabetes and CKD with eGFR as low as 30 mL per minute per 1.73 m2 should include metformin and an SGLT2 inhibitor to improve cardiovascular outcomes and limit CKD progression.

• ACE inhibitor or ARB treatment should be maximized in patients who have diabetes with albuminuria and hypertension unless complicated by symptomatic hypotension, uncontrolled hyperkalemia, or more than a 30% increase in creatinine level.

From the AFP Editors

Diabetes mellitus affects more than 450 million people globally, which could increase to more than 700 million people by 2045. Up to 40% of cases of diabetes are complicated by chronic kidney disease (CKD), with persistent abnormalities of kidney function demonstrated by elevated urine albumin excretion or reduced estimated glomerular filtration rate (eGFR). The Kidney Disease: Improving Global Outcomes (KDIGO) group, an international organization dedicated to nephrology clinical practice guidelines, has developed a new guideline for management of diabetes with CKD.

Team-Based Care

People with diabetes and CKD have high risks of CKD progression, cardiovascular disease (CVD), and mortality, which can be reduced with a comprehensive approach to lifestyle and risk factor management in combination with appropriate pharmacotherapy (Figure 1). Optimal care includes primary care, cardiology, nephrology, endocrinology, psychology, nutrition, and disease management nursing support.

FIGURE 1.

Multifactorial kidney-heart risk factor management. Glycemic control is based on insulin for type 1 diabetes mellitus and a combination of metformin and an SGLT2 inhibitor for type 2 diabetes, when the estimated glomerular filtration rate is 30 mL per minute per 1.73 m2 or higher. SGLT2 inhibitors are recommended for patients with type 2 diabetes and CKD. Renin-angiotensin system inhibition is recommended for patients with albuminuria and hypertension. Aspirin generally should be used for secondary prevention among those with established cardiovascular disease and may be considered for primary prevention among high-risk patients, with dual antiplatelet therapy used after acute coronary syndrome or percutaneous coronary intervention.

CKD = chronic kidney disease; SGLT2 = sodium-glucose cotransporter-2.

Adapted with permission from Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2020 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2020;98(4S):S22.


FIGURE 1.

Multifactorial kidney-heart risk factor management. Glycemic control is based on insulin for type 1 diabetes mellitus and a combination of metformin and an SGLT2 inhibitor for type 2 diabetes, when the estimated glomerular filtration rate is 30 mL per minute per 1.73 m2 or higher. SGLT2 inhibitors are recommended for patients with type 2 diabetes and CKD. Renin-angiotensin system inhibition is recommended for patients with albuminuria and hypertension. Aspirin generally should be used for secondary prevention among those with established cardiovascular disease and may be considered for primary prevention among high-risk patients, with dual antiplatelet therapy used after acute coronary syndrome or percutaneous coronary intervention.

CKD = chronic kidney disease; SGLT2 = sodium-glucose c

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

 

 

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