Prevention and management of chronic kidney disease in type 2 diabetes

Abstract

GUIDELINESBlood glucose control should be optimized aiming for a general HbA1c target 27%. (Grade A*). In people with type 2 diabetes and microalbuminuria or macroalbuminuria, angiotensin receptor blocker (ARB) or angiotensin-converting enzyme inhibitor ACEi antihypertensives should be used to protect against progression of kidney disease. (Grade A*). The blood pressure (BP) of people with type 2 diabetes should be maintained within the target range. ARB or ACEi should be considered as antihypertensive agents of first choice. Multi-drug therapy should be implemented as required to achieve target blood pressure. (Grade A*) People with type 2 diabetes should be informed that smoking increases the risk of chronic kidney disease (CKD) (Grade B*). Table A1: Definition of NHMRC grades of recommendation. Also refer to NHMRC 'National Evidence Based Guidelines for Diagnosis, Prevention and Management of CKD in Type 2 Diabetes' (see http://www.cari.org.au) for Levels of Evidence and Evidence Grading which were undertaken in accordance with the NHMRC Hierarchy of Evidence procedure. *Refer to SUGGESTIONS FOR CLINICAL CARE• The HbA1c target may need to be individualized taking in to account history of hypoglycaemia and co-morbidities. (refer to NHMRC Evidence Based Guideline for Blood Glucose Control in Type 2 Diabetes at http://www.nhmrc.gov.au).• Systolic blood pressure (SBP) appears to be the best indicator of the risk of CKD in type 2 diabetes. However, an optimum and safest lower limit of SBP has not been clearly defined.• In people with type 2 diabetes antihypertensive therapy with ARB or ACEi decreases the rate of progression of albuminuria, promotes regression to normoalbuminuria, and may reduce the risk of decline in renal function.• Due to potential renoprotective effects, the use of ACEi or ARB should be considered for the small subgroup of people with normal BP who have type 2 diabetes and microalbuminuria.• The extent to which interventions with lipid lowering therapy reduces the development of CKD in people with type 2 diabetes is unclear. As there is limited evidence relating to effects of lipid treatment on the progression of CKD in people with type 2 diabetes, blood lipid profiles should be managed in accordance with guidelines for prevention and management of cardiovascular disease (CVD).• Lifestyle modification (diet and physical activity) is an integral component of diabetes care (refer to the NHMRC Evidence Based Guidelines for Blood Glucose Control in Type 2 Diabetes), however, there are insufficient studies of suitable quality to enable dietary recommendations to be made with respect to prevention and/or management of CKD in people with type 2 diabetes. BACKGROUND Aim of the guidelineThis guideline topic has been taken from the NHMRC 'National Evidence Based Guidelines for Diagnosis, Prevention and Management of CKD in Type 2 Diabetes' which can be found in full at the CARI website (http:// www.cari.org.au). The NHMRC guideline covers issues related to the assessment and prevention of CKD in individu...

Serum bicarbonate concentration and the risk of cardiovascular disease and death in type 2 diabetes: the Fremantle Diabetes Study

“…A recent systematic review of the few trials of oral bicarbonate therapy in patients with CKD confirmed preservation of renal function and reduced incidence of progression to renal replacement therapy in bicarbonate-treated patients, and recommended that large, well-controlled trials of bicarbonate treatment should be carried out [ 26 ]. Although some guidelines for CKD management include oral alkalinization therapy for selected patients, current US and Australian guidelines for prevention and management of CKD in type 2 diabetes do not recommend bicarbonate therapy [ 1 , 27 ]. Our observation of an independent association between serum bicarbonate and CHD risk adds impetus to calls for high quality trials of bicarbonate therapy with mortality and cardiovascular end-points, as well as renal outcomes [ 28 , 29 ].…”

Gaps and barriers in health-care provision for co-morbid diabetes and chronic kidney disease: a cross-sectional study

“…Despite the recent publication of guidelines and consensus statements for the management of co-morbid diabetes and CKD [ 7 – 10 ], there is emerging evidence that the care of patients with these co-morbidities is suboptimal. Studies report a gap between recommended care, as suggested by guidelines, versus received care − a significant proportion of patients fail to meet treatment targets, and other recommended health indicators of quality clinical care such as treatment of cardiovascular risk factors or anaemia [ 11 – 14 ].…”

Recruitment of heterologous substrates by bacterial secretion systems for transkingdom translocation

“…(Coburn et al, 2007;Horna and Ruiz, 2021). These systems are involved in a variety of activities that require close interaction between the bacteria and the host cells, such as the modulation of the actin cytoskeleton for cell invasion, prevention of phagocytosis, interfering with immune response or promoting nodule formation (Sory and Cornelis, 1994;Jarvis et al, 1995;Marketon et al, 2005;Shaw et al, 2005;Holmes et al, 2010;Mou et al, 2018). Translocation of the substrates (generally called effectors) through the T3SS is essential for the virulence of many different pathogens.…”