Recently, the American Diabetes Society (ADA) and the Global Organization for Prognosis of Kidney Disease (KDIGO) jointly released a consensus on the management of diabetes in patients with kidney disease. The consensus suggests that diabetes patients have been screened for kidney disease every year after diagnosis, and focuses on how to use existing hypoglycemic drugs to delay the progress of diabetes nephropathy , while reducing diabetes complications .
In terms of treatment, three novel drugs, metformin, ACEI/ARB, sodium-glucose cotransporter 2 inhibitor (SGLT2i), glucagon-like peptide receptor agonist (GLP-1 RA), and nonsteroid-selective mineralocorticoid receptor antagonist Finerenone, were recommended.
This consensus also highlights new evidence for the use of SGLT2i in patients with glomerular filtration rate (eGFR) as low as 20 mL/min/1.73 m2.
, which includes:
1. All patients with diabetes should receive comprehensive treatment, including nutrition, exercise, smoking cessation and weight management, and lowering glycemics, and blood sugar, blood pressure, blood lipids, , meet the standards.
Figure 1 Comprehensive strategy for improving diabetic nephropathy
2. For patients with diabetes, hypertension , and proteinuria, the maximum dose of ACEI or ARB should be used.
3. All patients with diabetes nephropathy are advised to use statins.
4. All patients with type 2 diabetic nephropathy who have eGFR ≥30 mL/min/1.73 m2 are recommended to use metformin, and it is also recommended to adjust the dose based on eGFR.
5. It is recommended to treat all patients with type 2 diabetic nephropathy with eGFR ≥20 mL/min/1.73 m2 with SGLT2i, which has proven to benefit the kidney and cardiovascular system. It is also recommended that once SGLT2i treatment is initiated, treatment will continue even if the patient's eGFR is below this minimum.
6. This consensus includes GLP-1RA as the second-line treatment for patients with type 2 diabetes nephropathy. GLP-1RA can be considered if the blood sugar level is not met with metformin and SGLT2i, or if these drugs are not available.
Most of these drugs are safe in patients with eGFR levels below 15 mL/min/1.73 m2.
7. For patients with type 2 diabetes nephropathy whose eGFR ≥25 mL/min/1.73 m2, albumin /creatinine ratio ≥30 mg/g, normal blood potassium levels, and RAS inhibitor has reached the maximum tolerated dose, Finerenone is recommended.
Source: de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2022 Sep 27.
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