KDIGO 2022 Diabetes Management in CKD Guideline: A Topline Look at the Focused Update
Publication of the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (CKD) late in 2022 followed by just 2 years KDIGO's original guideline on this clinical area published in 2020. Motivation for the update, according to the writing group, came from the "wealth of high quality new evidence" that has become so rapidly available since the 2020 iteration as well as from the growing need for guidance to apply the plentiful new data.
The majoirty of the new evidence relates to the cardiorenal protective benefits of 3 drug classes in particular: sodium-glucose co-transporter-2 inhibitors (SGLT2i), the glucagon-like peptide-1 receptor agonists (GLP-1 RA), and the new class of nonsteroidal mineralocorticoid receptor antagonists (MRA). Guideline Chapters 1 (Comprehensive care) and 4 (Glucose-lowering therapies) were revised for the use of SGLT2i and GLP-1 RA, and a new section was developed. for the nonsteroidal MRA.
For this Guideline Topline, the editors chose to highlight the new recommendations and practice points related to clinical use of these 3 drug classes in perons with diabetes and chronic kidney disease (CKD) and to summarize the writing committee's rationale. Click through.
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KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease
Sodium-glucose cotransporter-2 inhibitors. SGLT2i should be used for patients with T2D and CKD—regardless of glycemia
KDIGO Recommendation 1.3.1. We recommend treating patients with T2D, CKD, and an eGFR ≥20 ml/min/1.73 m2 with an SGLT2i.
KDIGO SGLT2i Practice Point. "...if patients are already being treated with other glucose-lowering agents, an SGLT2i can be added to the current treatment regimen."
KDIGO SGLT2i Practice Point. "A reversible decrease in the eGFR with initiation of SGLT2i treatment may occur and is generally not an indication to discontinue therapy."
KDIGO SGLT2i Practice Point. "...the recommendation to use SGLT2i does not apply to kidney transplant recipients."
Nonsteroidal mineralocorticoid receptor antagonists. The recommendation for use of a nonsteroidal MRA with proven kidney or cardiovascular benefit is based on high-quality evidence from the FIGARO-DKD and FIDELIO-DKD clincal trials.
KDIGO Recommendation 1.4.1. "We suggest a nonsteroidal mineralocorticoid receptor antagonist (MRA) with proven renal or CV benefit for patients with T2D, eGFR ≥25 ml/min/1.73 m2, normal serum potassium concentration, and albuminuria (≥30 mg/g) despite maximum tolerated dose of RAS inhibitor."
Nonsteroidal MRA Therapy – Practice Point. "Nonsteroidal MRA are most appropriate for patients with T2D who are at high risk of CKD progression and CV events, as demonstrated by persistent albuminuria despite other standard-of-care therapies."
Nonsteroidal MRA Therapy – Practice Point. "The choice of a nonsteroidal MRA should prioritize agents with documented renal or CV benefits."
Glucagon-like peptide-1 receptor agonists. GLP-1 RA remain the KDIGO recommended second-line drug class for glucose-lowering in T2D and CKD.
KDIGO Recommendation 4.2.1. In patients with T2D and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2i treatment, or who are unable to use those medications, we recommend a long-acting GLP-1 RA.
GLP-1 RA Therapy Practice Point. "To minimize gastrointestinal side effects, start with a low dose of GLP-1 RA, and titrate up slowly."
GLP-1 RA Therapy Practice Point. "GLP-1 RA may be preferentially used in patients with obesity, T2D, and CKD to promote intentional weight loss."
Reference: Boer IH, Rossing P, Chan JCN, et al. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2022;102 (Suppl 5S), S1–S127. doi:10.1016/j.kint.2022.06.013
