New Consensus on Diabetes and Chronic Kidney Disease Together

Mitchel L. Zoler, PhD

October 05, 2022

The American Diabetes Association (ADA) and the Kidney Disease: Improving Global Outcomes (KDIGO) organization have together spelled out broad agreement on how clinicians should now manage patients with diabetes and chronic kidney disease (CKD) in a new consensus report published online October 3 in Diabetes Care and Kidney International.

The report focuses on how to use available diabetes medications to optimize slowing the progression of CKD while also applying best practices for controlling glycemia and minimizing other diabetes complications. It also highlights new evidence supporting use of agents from the sodium-glucose cotransporter 2 (SGLT2) inhibitor class in patients with an estimated glomerular filtration rate (eGFR) as low as 20 mL/min/1.73m2.

A major thrust of the consensus is a framework that details how clinicians can best orchestrate three new, important drug classes that have revolutionized management of CKD in people with diabetes: SGLT2 inhibitors, glucagon-like peptide (GLP)-1 agonists, and nonsteroidal mineralocorticoid receptor antagonists (specifically finerenone).

The report also guides use of these new agents in concert with two well-established mainstays for treating these patients — metformin and renin-angiotensin system inhibitors (angiotensin-converting enzyme [ACE] inhibitor or angiotensin II receptor blocker [ARB]) — for the many patients with diabetes and CKD who also have hypertension and albuminuria.

The planned consensus report was discussed at the ADA 82nd Scientific Sessions.

"These are very important drugs that are vastly underused," commented Josef Coresh, MD, PhD, at the time. "Coherence and simplicity are what we need so that there are no excuses about moving forward" with the recommended combination treatment, stressed Coresh, an epidemiologist and professor at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, who specializes in CKD and was not involved with the new statement.

"Broad Agreement" Between ADA and KDIGO

The writing panel says the goal of the consensus report is to highlight shared recommendations from the ADA's updated Standards of Medical Care in Diabetes — 2022  and KDIGO's 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.

The document represents "broad agreement" between the two groups on the "evidence-based management of adults with diabetes and CKD," they note.

It contains seven specific consensus statements:

  1. All patients with diabetes (type 1 or type 2) and CKD should receive treatment according to a "comprehensive plan" that adds pharmacologic management to the important lifestyle steps of optimized nutrition, exercise, smoking cessation, and weight goals, while also applying other therapies aimed at attaining target levels of glycemia, blood pressure, and lipids.

  2. Treatment with an ACE inhibitor or ARB is important for all patients with diabetes, hypertension, and albuminuria, titrated to maximum doses.

  3. Statin treatment is necessary for all people with diabetes and CKD at moderate or high intensity depending on other clinical features.

  4. The report recommends metformin for all patients with type 2 diabetes, CKD, and an eGFR of at least 30 mL/min/1.73m2, along with recommendations on eGFR-based dose adjustments for metformin.

  5. The panel also recommends treatment with an SGLT2 inhibitor with proven renal or cardiovascular benefits for all patients with type 2 diabetes, CKD, and an eGFR of at least 20 mL/min/1.73m2. The report advises continued treatment with an SGLT2 inhibitor once started even if a patient's eGFR dips below this minimum.

  6. The report puts treatment with a GLP-1 agonist second-line for patients with type 2 diabetes and CKD who do not reach their glycemic target on metformin and an SGLT2 inhibitor, and for patients unable to use these classes of drugs first-line. It specifies using agents from the GLP-1 agonist class with proven cardiovascular benefit and notes most agents from the class are safe even in patients with eGFR levels below 15 mL/min/1.73m2.

  7. Finally, the panel recommends using an agent from the nonsteroidal mineralocorticoid receptor antagonist class with proven kidney and cardiovascular benefits for patients with type 2 diabetes, CKD, and an eGFR of at least 25 mL/min/1.73m2, with an albumin-to-creatinine ratio of at least 30 mg/g, a normal serum potassium level, and on a maximum-tolerated dose of a renin-angiotensin system inhibitor. The only agent that currently fits these criteria is finerenone (Kerendia).

The consensus report had no commercial funding; several members of the writing panel have reported commercial disclosures.

Diabetes Care. Published online October 3, 2022. Full text

Kidney Int. Published online October 3, 2022. Full text

Mitchel L. Zoler is a reporter for Medscape and MDedge based in the Philadelphia area. @mitchelzoler

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