The recently released Kidney Disease: Improving Outcomes Globally (KDIGO) 2022 Clinical Practice Guideline, an update to the 2020 guideline of the same name, advocates a comprehensive approach to patient care.
Given the new high-quality evidence, the update included control for multiple risk factors and cooperative partnerships between patients chronic kidney disease (CKD) When DiabetesIt is intended to help , healthcare providers, and healthcare systems implement evidence-based recommendations that have demonstrated improved clinical outcomes.
Under the team led by Peter Rossing, Steno Diabetes Center Copenhagen, and Ian H. de Boer at the University of Washington Nephrology Institute, the overall scope and systematic literature search of the update is unchanged from the original guidelines.
Lifestyle interventions, a tiered approach to care, are a key feature of the recommendations, and the new update includes treatments proven to improve cardiovascular and renal outcomes. increase. Despite other guidelines that advocate multifactorial therapy as a ‘pillar’ of care, KDIGO’s stratified approach allows new therapy to be initiated with a single method and patient response and residual risk to be reassessed. to further improve treatment.
The updated guidelines include 13 recommendations and 52 action points for clinicians treating patients with diabetes and chronic kidney disease (CKD).
“With new therapies that can slow the progression of CKD and reduce the burden of cardiovascular disease, including heart failure, providers should focus on preserving kidney function and maintaining health rather than replacing it.” wrote the authors of the study. Beneficial effects offer the opportunity to meet these goals and save millions of lives, but these treatments will only benefit people with diabetes and CKD if they are widely implemented. increase.”
SGLT2 inhibitor
The KDIGO 2020 guidelines recommend SGLT2 inhibitors for people with renal disease and an estimated glomerular filtration rate (eGFR) of at least 30 mL/min/1.73m.2Updated guidelines recommend initiation of SGLT2 inhibitor therapy in patients with an eGFR ≥20 mL/min/1.73 m.2.
Since the publication of the original guideline, seven large-scale trials investigating the effects of SGLT2 inhibitors have reported positive results, justifying lowering of eGFR thresholds. In the guidelines, the topic was moved from Chapter 4 (Glycemic-Lowering Therapy in Patients with Type 2 Diabetes and CKD) to Chapter 1 (Comprehensive Care in Patients with Diabetes and CKD).
The guideline authors noted the change, acknowledging evidence from seven included trials that the benefits of SGLT2 inhibitors were independent of glycemic control, and that SGLT2 inhibitors were recommended for heart and kidney protection in patients with CKD. We recommend that you use
A new practice point (1.3.1) is that SGLT2 inhibitor recommendations are for renal and cardiovascular protection, and that SGLT2 inhibitors have safety and benefits in patients with CKD, even those without T2D. is shown. If the patient is already being treated with other hypoglycemic agents, her SGLT2i can be added to the current treatment regimen.
GLP-1 RA
The second-line drug class recommended for hypoglycemic agents in type 2 diabetes and CKD remained GLP-1 RA. According to the authors, a single new trial (AMPLITUDE-O) adds to the evidence for cardiovascular benefits of GLP-1 RA and hypothesizes that GLP-1 RA may also improve renal outcomes was reinforced.
Because the cardiovascular benefits of GLP-1 RA have been reported across eGFR strata, this class should be considered for T2D and CKD patients who have not achieved glycemic targets despite the use of SGLT2 inhibitors and metformin. is the preferred glucose-lowering drug for
A new practice point was added to suggest that GLP-1 RA is preferentially used in patients with obesity, T2D, and CKD to promote intentional weight loss.
Nonsteroidal MRA
The updated guidelines included a new section on the use of MRA. MRA has been shown to reduce residual proteinuria in individuals receiving renin-angiotensin system (RAS) inhibitors.
A small clinical trial reported an antiproteinuria effect of steroid MRA without developing hyperkalemia, but a beneficial effect of steroid MRA on kidney disease progression was not established.
Based on high-quality evidence from the FIGARO-DKD and FIDELIO-DKD trials, renal or cardiovascular benefits, including finerenone, have been demonstrated in patients with type 2 diabetes and eGFR ≥25 ml/min/1.73. The use of non-steroidal MRA is currently recommended.meters2normal serum potassium levels, and albuminuria despite receiving the maximum tolerated dose of RAS inhibitors.
This recommendation is considered Grade 2A (Weak or Recommended). Reasons for this are the availability of efficacy and safety data for only one agent in the class, the low representation of patients with moderate albuminuria, and the lack of data on the additive effects of SGLT2 inhibitors and MRA. A lack of real-world data demonstrating the safety and safety of non-steroidal MRA.
Implementation
The authors noted that implementation requires community outreach efforts to make care accessible and equitable, as well as greater focus on patient preferences and priority-building strategies.
Cost is a distinct barrier to implementation. However, the team suggested that using these agents to avoid or delay expensive renal replacement therapy could ultimately make it more cost-effective to implement new treatments. but more data is collected to support broader access.
“Creating a compelling case for using CKD treatments as part of a health systems strategy for value-based care will lower the cost of new treatments and translate theoretical cost-benefit analyzes into reality. essential for,” they wrote.
“Diabetes Management in Chronic Kidney Disease: An Overview of the KDIGO 2022 Clinical Practice Guidelines Update‘ was published online. Annals of Internal Medicine.
