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Synopsis of the KDIGO 2022 Clinical Practice Guideline Update on Diabetes Management in CKD
The KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease is an update of the 2020 guideline from Kidney Disease: Improving Global Outcomes (KDIGO).
The KDIGO Work Group updated the guideline, which included reviewing and grading new evidence that was identified and summarized. As in the previous guideline, the Work Group used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to appraise evidence and rate the strength of recommendations and expert judgment to develop consensus practice points. New evidence led to updating of recommendations in the chapters Comprehensive Care in Patients With Diabetes and CKD (Chapter 1) and Glucose-Lowering Therapies in Patients With T2D and CKD (Chapter 4). New evidence did not change recommendations in the chapters Glycemic Monitoring and Targets in Patients With Diabetes and CKD (Chapter 2), Lifestyle Interventions in Patients With Diabetes and CKD (Chapter 3), and Approaches to Management of Patients With Diabetes and CKD (Chapter 5).
The updated guideline includes 13 recommendations and 52 practice points for clinicians caring for patients with diabetes and chronic kidney disease (CKD). A focus on preserving kidney function and maintaining well-being is recommended using a layered approach to care, starting with a foundation of lifestyle interventions, self-management, and first-line pharmacotherapy (such as sodium-glucose cotransporter-2 inhibitors) demonstrated to improve clinical outcomes. To this are added additional drugs with heart and kidney protection, such as glucagon-like peptide-1 receptor agonists and nonsteroidal mineralocorticoid receptor antagonists, and interventions to control risk factors for CKD progression and cardiovascular events, such as blood pressure, glycemia, and lipids.
Disclosure statements are available on the authors' profiles:
Diabetes Management in Chronic Kidney Disease: Synopsis of the KDIGO 2022 Clinical Practice Guideline UpdateAnn. Intern. Med 2023 Jan 10;[EPub Ahead of Print], SD Navaneethan, S Zoungas, ML Caramori, JCN Chan, HJL Heerspink, C Hurst, A Liew, ED Michos, WA Olowu, T Sadusky, N Tandon, KR Tuttle, C Wanner, KG Wilkens, JC Craig, DJ Tunnicliffe, M Tonelli, M Cheung, A Earley, P Rossing, IH de Boer, K Khunti
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Diabetes management in chronic kidney disease – KDIGO 2022
A lot has changed in the last few years with regard to the management of chronic kidney disease (CKD). There have been good clinical trials with SGLT2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists (ns-MRA), and GLP-1 receptor agonists (RA). However, all these studies need to be merged with the existing treatments for CKD.
This KDIGO document nicely pulls together all of the components that we need to know for the management of patients with CKD. All of the research papers were summarized into two simple graphics.
The first graphic is a pyramid that shows the different treatment strategies. The base of the pyramid is made up of lifestyle factors: diet, exercise, smoking cessation, and weight reduction. The second layer is labeled “first-line drug therapy” which includes metformin, SGLT2 inhibitors, RAS inhibitors, and statins. Each of these agents has trials that have shown benefits in patients with CKD, and hence, they are the first-line therapies. The next layer of the pyramid is labeled “additional drugs with heart and kidney protection” and this section includes GLP-1 RA, ns-MRA, and antiplatelet therapies. Finally, the tip of the pyramid is tagged as “additional risk factor control” where they have listed glycemic control agents, blood pressure control agents, and lipid management agents. This section would include medications, such as antihyperglycemic agents, antihypertensive agents like calcium channel blockers and diuretics, and lipid-lowering therapies like ezetimibe and PCSK9 inhibitors.
The second figure takes the pyramid structure and makes it into a flow diagram where you start with the lifestyle factors at the top and then work your way down through the other therapeutics. In this flow diagram, there are more details for each of the therapies. For example, estimated glomerular filtration rate (eGFR) cut-off levels are listed as a quick reference for some of the agents. Throughout the two figures, patients with diabetes and without diabetes are flagged so that the recommendations become clear as to which patient population they were designed for.
These figures could even be shown to patients so that they know what the path forward for their CKD management will be. The more they understand, the better. The patients may ask what an eGFR is and we could tell them it is the speed at which one's kidney is filtering. We would like to see it over 60 mL/min/m2 and yours is 30 mL/min/m2 so this way patients know what the numbers mean.
Similarly, for ACR (albumin creatinine ratio), we can explain that this measures the quality of your kidney as a filter. A good filter keeps the good stuff in and gets rid of the bad stuff. The good stuff is protein like albumin and the bad stuff is creatinine, which is produced from the breakdown of muscle. Therefore, if you are getting rid of a lot of albumin then that is a bad quality filter. A high ACR means you are getting rid of lots of albumin, the good stuff, so that is a sign of a bad filter. If patients understand these fundamentals, and with these two simple figures, they understand the treatment algorithm, then the patients will become empowered and they will be active participants in their own care.
The KDIGO team has done a great job in making the guidelines easy to implement. The two figures together are easy to understand and hopefully, this will lead to patients getting the appropriate therapies.