Executive summary of the 2020 KDIGO Diabetes Management in CKD Guideline: evidence-based advances in monitoring and treatment
Recently there is a substantial increase in the public health burden of diabetes and chronic kidney disease (CKD). Due to continuous research and trials, there is the recent development of new therapies applicable to this population. The author Boer and colleagues (2020) published “Executive summary of the 2020 KDIGO Diabetes Management in CKD Guideline: evidence-based advances in monitoring and treatment” in The Kidney International (2020). This is the first-ever Kidney Disease: Improving Global Outcomes (KDIGO) Guideline for Diabetes Management in Chronic Kidney Disease. A summary of these guidelines is given below:
Objective:
To put forward evidence-based recommendations to enhance the clinical care of people with diabetes and CKD by combining new options with existing management strategies.
Method:
The guidelines are written by the International Work Group supported by a dedicated Evidence Review Team and professional KDIGO staff. A huge base of high-quality evidence from randomized clinical trials is used to list down the guidelines along with the clinical expertise. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework helped to evaluate the quality of evidence and strength of recommendations.
Recommendations:
Recommendations for comprehensive care in patients with diabetes and CKD :
Patients with diabetes and CKD should be treated with a comprehensive strategy to reduce the risks of kidney disease progression and cardiovascular disease. Guidelines recommend that treatment with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) should be initiated in patients with diabetes, hypertension, and albuminuria and that these medications should be titrated to the highest approved dose that is tolerated. It is recommended to advise patients with diabetes and CKD who use tobacco to quit using tobacco products.
Recommendations for glycemic monitoring and targets in patients with diabetes and CKD :
Using hemoglobin A1c (HbA1c) to monitor glycemic control in patients with diabetes and CKD is recommended. The recommended target for HbA1c is from <6.5% to <8.0% in patients with diabetes and CKD not treated with dialysis.
Recommendations for lifestyle interventions in patients with diabetes and CKD :
Patients with diabetes and CKD should consume a personalized diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts; and lower in processed meats, refined carbohydrates, and sweetened beverages. A protein intake of 0.8 g protein/kg (weight)/day for those with diabetes and CKD not treated with dialysis is suggested. Suggested sodium intake for patients with diabetes and CKD is <2 g of sodium per day. It is recommended that patients with diabetes and CKD should be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week or to a level compatible with their cardiovascular and physical tolerance.
Recommendations for antihyperglycemic therapies in patients with type 2 diabetes (T2D) and CKD :
Glycemic management for patients with T2D and CKD should be inclusive of lifestyle therapy, first-line treatment with metformin and a sodium-glucose cotransporter-2 inhibitor (SGLT2i), and additional drug therapy as required for glycemic control. Additionally, metformin is recommended in the treatment of patients with T2D, CKD, and an eGFR ≥30 ml/min per 1.73 m2. A treatment with SGLT2i is recommended in patients with T2D, CKD, and an eGFR ≥30 ml/min per 1.73 m2. Use of a long-acting glucagon-like peptide-1 receptor agonist (GLP-1 RA) is recommended in patients with T2D and CKD who have not achieved individualized glycemic targets despite using metformin and SGLT2i, or who are unable to consume those medications
Recommendations for approaches in the management of patients with diabetes and CKD :
It is recommended that a structured self-management educational program should be implemented for the care of people with diabetes and CKD. Additionally, guidelines suggest that policymakers and institutional decision-makers implement team-based, combine care focused on risk evaluation, and patient empowerment to provide comprehensive care in patients with diabetes and CKD.
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