The 2021–2022 position of Brazilian Diabetes Society on diabetic kidney disease (DKD) management: an evidence-based guideline to clinical practice. Screening and treatment of hyperglycemia, arterial hypertension, and dyslipidemia in the patient with DKD

Abstract

Background Diabetic kidney disease is the leading cause of end-stage renal disease and is associated with increased morbidity and mortality. This review is an authorized literal translation of part of the Brazilian Diabetes Society (SBD) Guidelines 2021–2022. This evidence-based guideline provides guidance on the correct management of Diabetic Kidney Disease (DKD) in clinical practice. Methods The methodology was published elsewhere in previous SBD guidelines and was approved by the internal institutional Steering Committee for publication. Briefly, the Brazilian Diabetes Society indicated 14 experts to constitute the Central Committee, designed to regulate methodology, review the manuscripts, and make judgments on degrees of recommendations and levels of evidence. SBD Renal Disease Department drafted the manuscript selecting key clinical questions to make a narrative review using MEDLINE via PubMed, with the best evidence available including high-quality clinical trials, metanalysis, and large observational studies related to DKD diagnosis and treatment, by using the MeSH terms [diabetes], [type 2 diabetes], [type 1 diabetes] and [chronic kidney disease]. Results The extensive review of the literature made by the 14 members of the Central Committee defined 24 recommendations. Three levels of evidence were considered: A. Data from more than 1 randomized clinical trial or 1 metanalysis of randomized clinical trials with low heterogeneity (I2 < 40%). B. Data from metanalysis, including large observational studies, a single randomized clinical trial, or a pre-specified subgroup analysis. C: Data from small or non-randomized studies, exploratory analyses, or consensus of expert opinion. The degree of recommendation was obtained based on a poll sent to the panelists, using the following criteria: Grade I: when more than 90% of agreement; Grade IIa 75–89% of agreement; IIb 50–74% of agreement, and III, when most of the panelist recommends against a defined treatment. Conclusions To prevent or at least postpone the advanced stages of DKD with the associated cardiovascular complications, intensive glycemic and blood pressure control are required, as well as the use of renin–angiotensin–aldosterone system blocker agents such as ARB, ACEI, and MRA. Recently, SGLT2 inhibitors and GLP1 receptor agonists have been added to the therapeutic arsenal, with well-proven benefits regarding kidney protection and patients’ survival.

A Narrative Review of New Treatment Options for Diabetic Nephropathy

“…RAAS lowering with angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) is the first-line treatment for the clinical management of DKD [ 29 ]. GLP-1 receptor agonists have been added to the treatment toolkit because of their well-established benefits for kidney protection and patient survival [ 30 ]. Evidence from cardiovascular outcome trials using SGLT-2 inhibitors strongly suggested that these drugs, in addition to standard-of-care therapy, significantly slowed the course of CKD in people with diabetes mellitus [ 31 ].…”

Bloqueo del eje renina angiontensina aldosterona (RAAS) en la enfermedad renal diabética. Más allá del control de la hipertensión arterial

“…El tratamiento intensivo de la PA en pacientes con ERD es parte del cuidado usual recomendado actualmente por las diferentes guías de manejo dado su beneficio en retrasar la progresión de la ERD y reducción de eventos cardiovasculares adversos (6). Tempranamente en la historia del control de la PA en pacientes con ERD se ha demostrado los beneficios de su reducción, el primer bloqueador del sistema RAAS utilizado en pacientes con HTA y DM fue el captopril el cual logró demostrar que el control de la presión arterial (PA) tendría beneficios en la reducción de albuminuria (8).…”

“…Dentro de la estrategia de tratamiento y gestión de riesgo en pacientes con enfermedad renal diabética, la identificación de factores de riesgo modificables y potencialmente modificables es fundamental para guiar estrategias de tratamiento (6). En este sentido los factores de riesgo para progresión de la ERD incluyen hiperglicemia, hipertensión arterial, albuminuria, dislipidemia, tabaquismo, obesidad, dieta inadecuada y estilos de vida sedentarios (6,7). Por ello, además de plantearnos una meta de presión arterial se buscará impactar sobre componentes adicionales del riesgo cardiovascular y progresión de la ERD (6,7).…”

“…En este sentido los factores de riesgo para progresión de la ERD incluyen hiperglicemia, hipertensión arterial, albuminuria, dislipidemia, tabaquismo, obesidad, dieta inadecuada y estilos de vida sedentarios (6,7). Por ello, además de plantearnos una meta de presión arterial se buscará impactar sobre componentes adicionales del riesgo cardiovascular y progresión de la ERD (6,7).…”

“…Rico Fontalvo, Jorge 1,2,3 ; Montejo Hernández, Juan 2,3 ; Vázquez Jiménez, Lourdes 4,5 ; Rodríguez Yánez, Tomás 6 ; Daza Arnedo, Rodrigo 2 ; Cardona Blanco, María Ximena 3 ; López Lozano, Jhon 7 ; Plaza Rivero, Mayerlys 7 Bloqueo del eje renina angiontensina aldosterona (RAAS) en la enfermedad renal diabética. Más allá del control de la hipertensión arterial Renin angiotensin aldosterone system (RAAS) and its suppression in diabetic kidney disease.…”