More than 40% of people with diabetes develop CKD, and a significant number develop kidney failure requiring dialysis or transplant. The Kidney Disease: Improving Global Outcomes (KDIGO) group saw an opportunity to address this issue and wrote a recently published guideline on diabetes management in patients with chronic kidney disease (CKD).*

The KDIGO guideline offers 12 recommendations and 48 practice points for clinicians who care for patients with diabetes and CKD, such as nephrologists, primary care doctors, and non-nephrology specialists. The information provided in the guideline includes:

• Comprehensive care needs
• Glycemic monitoring and targets
• Lifestyle interventions
• Glucose-lowering therapies
• Educational/integrated care approaches

Medical recommendations

The guideline panel focused on various treatment and monitoring methods for patients with diabetes and CKD. 

They recommend treatment with an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker (renin-angiotensin system (RAS) blockade) for patients with diabetes, hypertension, and albuminuria (when the albumin-creatinine ratio exceeds 30 mg/g). Titration of the medication and close monitoring of serum potassium and serum creatinine levels within two to four weeks of initiation or change in dose are suggested. 

They also recommend the following:

• Patients with diabetes and CKD who smoke or use tobacco should be advised to quit.
• A hemoglobin A1c test should be used to monitor glycemic control in patients with diabetes and CKD who are not receiving dialysis.
• Treatment with both metformin and an SGLT2 inhibitor, such as canagliflozin, is recommended for patients with type 2 diabetes, CKD, and an estimated glomerular filtration rate (eGFR) that is equal to or greater than 30 mL/min/1.73m2.
• For those who do not achieve glycemic targets or who cannot take those medications, a long-acting glucagon-like peptide-1 (GLP-1) receptor agonist can be used instead.

Dietary and lifestyle changes 

In addition to medication and lab work for monitoring one’s health status, the guideline also makes dietary and lifestyle suggestions to effectively manage diabetes in CKD patients. 

For the general population, a healthy diet is:

• High in vegetables, fruits, whole grains, fiber, and legumes
• Low in processed meats, refined carbohydrates, and sweetened beverages

A diet for CKD patients with diabetes is similar, except for protein and sodium, or salt, intake. 

Research has not shown protein restriction to reduce glomerular hyperfiltration or slow kidney disease progression, which challenges earlier claims that a low-protein diet was necessary. Therefore, a protein intake at 0.8 g/kg/day is advised for those with diabetes and CKD who are not on dialysis. For patients on dialysis, they can increase daily protein intake to 1.0 to 1.2 g/kg/day.

Kidney function decline is associated with sodium retention that can raise cardiovascular risk. Thus, sodium should be limited to less than 2,000 mg/day. The panel also recommends physical activity of moderate intensity for at least 150 minutes per week, or to tolerance.

According to Sankar D. Navaneethan, M.D., the guideline’s first author, “We wanted to emphasize how important lifestyle is. It’s the foundation you want to build on. You can take medications without all these other things—exercise, diet, weight loss—but they won’t be nearly as effective.”

The guideline also emphasizes the need for self-management educational programs, and it encourages policymakers and institution decision-makers to focus on the implementation of comprehensive, integrative, team-based care for patients with diabetes and CKD.

*Tucker, M. E. (2020, Nov. 9). New Guidelines Address Diabetes Management in Kidney Disease. Medscape. https://www.medscape.com/viewarticle/940631