ADA, KDIGO offer consensus statements on managing diabetes and chronic kidney disease

All patients with type 1 or type 2 diabetes and chronic kidney disease (CKD) should have a treatment plan developed with their clinicians to optimize nutrition, exercise, smoking cessation, and weight, according to a recent statement from the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). The plan should also incorporate evidence-based pharmacologic therapies to preserve organ function and other therapies aimed at attaining intermediate glycemia, blood pressure, and lipid targets, the statement said.

Representatives from the ADA and from KDIGO reviewed and developed consensus statements based on shared recommendations from both organizations' 2022 guidelines to help guide care in patients with diabetes and CKD. The consensus report was published simultaneously Oct. 3 by Diabetes Care and Kidney International.

The consensus statements included the following:

• An angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker is recommended for patients with type 1 or type 2 diabetes who have hypertension and albuminuria, titrated to the maximum antihypertensive or highest tolerated dose.
• A statin is recommended for all patients with type 1 or type 2 diabetes and CKD, at moderate intensity for primary prevention of atherosclerotic cardiovascular disease (ASCVD) or at high intensity for patients with known ASCVD and for some patients with multiple ASCVD risk factors.
• Metformin is recommended for patients with type 2 diabetes, CKD, and an estimated glomerular filtration rate (eGFR) of at least 30 mL/min/1.73 m². The dose should be reduced to 1,000 mg/d in patients with an eGFR of 30 to 44 mL/min/1.73 m² and in some patients with an eGFR of 45 to 59 mL/min/1.73 m² who are at high risk of lactic acidosis.
• A sodium-glucose cotransporter-2 (SGLT-2) inhibitor with proven kidney or cardiovascular benefit is recommended for patients with type 2 diabetes, CKD, and an eGFR of at least 20 mL/min/1.73 m². Once started, the drug can be continued at lower eGFR levels, the statement said.
• A glucagon-like peptide-1 receptor agonist with proven cardiovascular benefit is recommended for patients with type 2 diabetes and CKD who do not meet their individualized glycemic target with metformin and/or an SGLT-2 inhibitor or are unable to take these drugs.
• A nonsteroidal mineralocorticoid receptor antagonist (e.g., finerenone) with proven kidney and cardiovascular benefit is recommended for patients with type 2 diabetes, an eGFR of at least 25 mL/min/1.73 m², a normal serum potassium level, and albuminuria (albumin-to-creatinine ratio ≥30 mg/g) despite the maximum tolerated dose of a renin-angiotensin system inhibitor.

“Implementation of proven therapies is paramount to improving health outcomes. There is a critical need for patients with diabetes and CKD to be treated in accord with the most up-to-date recommendations. The ADA and KDIGO, individually and now in combination, offer clear guidance on applying and prioritizing interventions,” the statement said. “High cost, limited workforce, and other resource constraints in health care systems will limit implementation of some recommendations among individuals and populations, and efforts to improve accessibility are essential to maximizing benefit and minimizing disparities.”