Chronic Kidney Disease in Diabetes

Abstract

Identification of chronic kidney disease in people with diabetes requires screening for proteinuria, as well as an assessment of serum creatinine converted into an estimated glomerular function rate (eGFR). • All individuals with chronic kidney disease should be considered at high risk for cardiovascular events and should be treated to reduce these risks. • The development and progression of renal damage in diabetes can be reduced and slowed through intensive glycemic control and optimization of blood pressure. Progression of chronic kidney disease in diabetes can also be slowed through the use of medications that disrupt the renin angiotensin aldosterone system. KEY MESSAGES FOR PEOPLE WITH DIABETES • The earlier that the signs and symptoms of chronic kidney disease in diabetes are detected, the better, as it will reduce the chance of progression to advanced kidney disease and the need for dialysis or transplant. • You should have your blood and urine tested annually for early signs of chronic kidney disease in diabetes. • If you are found to have signs of chronic kidney disease, your health-care provider may recommend lifestyle or medication changes to help delay more damage to your kidneys. PRACTICAL TIPS Management of Potassium and Creatinine During the Use of Angiotensin Converting Enzyme (ACE) inhibitor or Angiotensin II Receptor Blocker (ARB) or Direct Renin Inhibitor (DRI) Therapy • Check serum potassium and creatinine at baseline and within 1 to 2 weeks of initiation or titration of therapy AND during times of acute illness. • If potassium becomes elevated or creatinine increases by more than 30% from baseline, therapy should be reviewed and serum creatinine and potassium levels should be rechecked. • Mild-to-moderate stable hyperkalemia: • Counsel on a low-potassium diet. • If persistent, non-potassium-sparing diuretics and/or oral sodium bicarbonate (in those with a metabolic acidosis) should be considered. • Consider temporarily reducing or holding RAAS blockade (i.e. ACE inhibitor, ARB or DRI). • Severe hyperkalemia: • In addition to emergency management strategies, RAAS blockade should be held or discontinued. Conflict of interest statements can be found on page S207. Figure 1. Causes of CKD in people with and without diabetes. CKD, chronic kidney disease. Can J Diabetes 42 (2018) S201-S209 Contents lists available at ScienceDirect Canadian Journal of Diabetes j o u r n a l h o m e p a g e : w w w. c a n a d i a n j o u r n a l o f d i a b e t e s. c o m

The role of sodium glucose cotransporter-2 (SGLT-2) inhibitors in heart failure and chronic kidney disease in type 2 diabetes

“…Guidelines recommend testing UACR and eGFR immediately at diagnosis of T2D and at least yearly thereafter. Persistent albuminuria and/or eGFR below 60 mL/min/1.73 m 2 , maintained over 3 months, supports a diagnosis of CKD 60 . Management depends in part on controlling hypertension, and in part on achieving effective glycemic control, which appears to decrease the risk of developing CKD 61,62 and to delay progression of renal dysfunction 63 .…”

“…Management depends in part on controlling hypertension, and in part on achieving effective glycemic control, which appears to decrease the risk of developing CKD 61,62 and to delay progression of renal dysfunction 63 . RAAS-blocking antihypertensive agents (angiotensin II converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs)), which protect from incidence or progression of renal damage in a variety of contexts, are recommended in individuals with T2D and CKD 60 .…”

“…Renal benefits include prevention of both early (incidence of macroalbuminuria) and late (onset of dialysis; death from renal disease) CKD events. Because these effects were independent of baseline renal function 69 , it appears that SGLT-2 inhibitors might be beneficial for individuals with or without prior CKD 19,22,60,89,96,97 .…”

Diagnostic Assessment of Cases with Chronic Kidney Disease with Diabetes Mellitus Type 2

“…18 We proposed a combined use of eGFR and ACR for early detection of renal dysfunction as against serum creatinine, a common measurement for kidney function in routine practice, considering it to be a poor marker of kidney dysfunction. 19 We adopted MDRD equation to compute eGFR. Another, important marker for kidney impairment is albuminuria, Albumin Creatinine Ratio (ACR).…”

Management of type 2 diabetes using non‐insulin glucose‐lowering therapies: a critical appraisal of clinical practice guidelines with the AGREE II instrument

“…Quality of guidelines on type 2 diabetes using the AGREE instrument (expressed as percentage) Scores range between 0 and 100%. Overall quality of guideline was assessed using a scoring system(1)(2)(3)(4)(5)(6)(7). Strongly recommended, four of six domains ≥ 60%; recommended with modifications, at least two domain scores > 60%; and no (guideline is not recommended due to very serious problems according to AGREE criteria), three of six domains scores < 30% or none of the domains > 60%.ADA, American Diabetes Association; AACE/ACE, American Association of Clinical Endocrinologists/American College of Endocrinologists, ACP, American College of Physicians, AGREE II, Appraisal of Guidelines, Research and Evaluation II; ICSI, Institute for Clinical Systems Improvement; NICE, National Institute for Health and Clinical Excellence; VA/DoD: Veterans Affairs and Department of Defense; WHO, World Health Organization.…”