Yep, I’m on the kidney ‘stream’ again, as the American Diabetes Association (ADA) and the Kidney Disease:Improving Global Outcomes (KDIGO) have recently released a new Consensus Statement with key recommendations on treating chronic kidney disease in people with diabetes.
Key points include: (note, I have included links throughout for further information or to explain terminology)
- Patients and their health care team should work together to create a plan around health nutrition, physical activity, smoking cessation and weight management. (Note: creating a nutrition plan for people with CKD can be challenging, as many people with CKD have limitations on things like sodium (salt), potassium, and protein. Having a health care team knowledgeable of how to navigate these challenges is important.)
- Control of blood sugar, blood pressure, and cholesterol is important.
- We are reminded of the importance of ACE inhibitor or ARB medication for people with hypertension and albuminuria, titrated to maximum tolerated doses. (Note – our Diabetes Canada guidelines also recommend ACE or ARB for people with albuminuria even if they don’t have hypertension, provided their blood pressure has enough ‘room’ for the BP lowering effects.)
- Statin therapy at moderate to high intensity dosing is recommended for people with diabetes and CKD, with dosing dependent on clinical risk factors for/presence of cardiovascular disease.
- We are reminded that metformin can be used in people with type 2 diabetes and CKD, provided GFR is 30 or greater. The maximum dose is lower for people with GFR 30-60 (check out this awesome renal dosing table for diabetes medications, from Diabetes Canada, here).
- A GLP1 receptor agonist (GLP1RA) with cardiovascular benefit is recommended for people with type 2 diabetes who don’t reach blood sugar goals with metformin and an SGLT2i, and those who are unable to use those classes of medication. (Note that in both the Canadian and American diabetes treatment guidelines, GLP1RA should be considered in people with, or at high risk for, cardiovascular disease, even if their sugars are at target. Some GLP1RAs can also be very helpful for weight loss.) They note that GLP1RAs are quite safe for people with CKD, and have been studied down as far as GFR of 15.
- A nonsteroidal mineralocorticoid receptor antagonist (finerenone is the only one currently available, and just recently approved in Canada) is recommended in people with type 2 diabetes, normal potassium, GFR ≥25 with albuminuria despite maximum dose of ACE or ARB.
How can we treat type 2 diabetes in people with more advanced CKD (GFR <30)? This consensus takes on this question head on, with key points including:
- SGLT2 inhibitors are important for renal and cardiovascular benefit, for people with a GFR of 20 or greater. Continuation of treatment is advised once started, even if the GFR dips below 20.
- GLP1RAs retain their glucose lowering effect across the range of GFR, and even in dialysis patients, as noted in the consensus (though these medications are not approved for use in dialysis due to lack of formal studies in this patient group). Caution is recommended in people at risk of malnutrition, as GLP1Ras cause weight loss by reducing appetite and/or cravings, and can also cause nausea/vomiting as a potential side effect. (For people with obesity and CKD, as blogged previously, obesity is an independent risk factor for CKD, and weight loss is beneficial in this group.)
- Select DPP4 inhibitors can be used with GFR <30 and even in dialysis, some requiring reduced doses. (note: DPP4i and GLP1RA should not be used together as they work in similar ways to control blood sugars).
- People who have had a kidney transplant can generally be treated as for someone with the same GFR who hasn’t had a kidney transplant. (though data are lacking on glucose lowering medications specifically in people with kidney transplants).
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