Top 10 Takeaways from the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD

Released to coincide with World Diabetes Day earlier this month, the KDIGO have released a comprehensive set of guidelines that can be accessed on their website. For those too busy to read the full document, KDIGO has an illustrated summary reproduced below.

What is the KDIGO?

Global Science. Local Change. KDIGO is the global nonprofit organization developing and implementing evidence-based clinical practice guidelines in kidney disease.

Background to the guidelines

The Kidney Disease: Improving Global Outcomes (KDIGO) 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (CKD)represents the first KDIGO guideline on this subject. The scope includes topics such as comprehensive care, glycemic monitoring and targets, lifestyle and antihyperglycemic interventions, and approaches to self-management and optimal models of care.The goal of the guideline is to generate a useful resource for clinicians and patients by providing actionable recommendations with infographics based on a rigorous, formal systematic literature review. Another aim is to propose research recommendations for areas in which there are gaps in knowledge. The guideline targets a broad audience of clinicians treating diabetes and CKD while taking into account implications for policy and payment.The development of this guideline followed an explicit process of evidence review and appraisal. Treatment approaches and guideline recommendations are based on systematic reviews of relevant studies, appraisal of the quality of the evidence, and the strength of recommendations following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Limitations of the evidence are discussed and areas for future research are presented. 

The 10 Takeaways

  1. Comprehensive care

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).

2. Nutrition intake

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, rened 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.

3. Glycemic monitoring

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.

4. Glycemic targets

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.

5. SGLT2i

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.

6. Metformin

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 complications.

7. GLP-1 RA

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.

8. RAS blockade

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.

9. Approaches to management

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.

10. Research recommendations

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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