Tactics to prevent or slow progression of CKD in patients with diabetes

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doi:10.12788/jfp.0126

Applied Evidence

Tactics to prevent or slow progression of CKD in patients with diabetes

J Fam Pract. 2021 January;70(1):6-12 | 10.12788/jfp.0126

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References

1. Radbill B, Murphy B, LeRoith D. Rationale and strategies for early detection and management of diabetic kidney disease. Mayo Clin Proc. 2008;83:1373-1381.

2. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2017 Annual Data Report: Epidemiology of kidney disease in the United States. Am J Kidney Dis. 2018;71(3 suppl 1):A7.

3. Tuttle KR, Bakris GL, Bilous RW, et al. Diabetic kidney disease: a report from an ADA Consensus Conference. Am J Kidney Dis. 2014;64:510-533.

4. Fox CS, Matsushita K, Woodward M, et al; Chronic Kidney Disease Prognosis Consortium. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis. Lancet. 2012;380:1662-1673.

5. Orchard TJ, Dorman JS, Maser RE, et al. Prevalence of complications in IDDM by sex and duration. Pittsburgh Epidemiology of Diabetes Complications Study II. Diabetes. 1990;39:1116-1124.

6. American Diabetes Association. Standards of Medical Care in Diabetes—2018. Diabetes Care. 2018;41(suppl 1):S1-S159. Accessed January 5, 2021. https://care.diabetesjournals.org/content/41/Supplement_1

7. National Kidney Foundation. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3:1-150. Accessed January 5, 2021. https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf

8. Afkarian M, Zelnick LR, Hall YN, et al. Clinical manifestations of kidney disease among US adults with diabetes, 1988-2014. JAMA. 2016;316:602-610.

9. de Boer IH, Rue TC, Hall YN, et al. Temporal trends in the prevalence of diabetic kidney disease in the United States. JAMA. 2011;305:2532-2539.

10. de Boer IH; DCCT/EDIC Research Group. Kidney disease and related findings in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study. Diabetes Care. 2014;37:24-30.

11. Stanton RC. Clinical challenges in diagnosis and management of diabetic kidney disease. Am J Kidney Dis. 2014;63(2 suppl 2):S3-S21.

12. Mottl AK, Tuttle KR. Diabetic kidney disease: Pathogenesis and epidemiology. UpToDate. Updated August 19, 2019. Accessed January 5, 2021. www.uptodate.com/contents/diabetic-kidney-disease-pathogenesis-and-epidemiology

13. Bakris GL. Moderately increased albuminuria (microalbuminuria) in type 2 diabetes mellitus. UpToDate. Updated November 3, 2020. Accessed January 5, 2021. https://www.uptodate.com/contents/moderately-increased-albuminuria-microalbuminuria-in-type-2-diabetes-mellitus

14. Bandak G, Sang Y, Gasparini A, et al. Hyperkalemia after initiating renin-angiotensin system blockade: the Stockholm Creatinine Measurements (SCREAM) Project. J Am Heart Assoc. 2017;6:e005428.

15. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2016 Annual Data Report: Epidemiology of kidney disease in the United States. Am J Kidney Dis. 2017;69(3 suppl 1):A7-A8.

16. Nilsson E, Gasparini A, Ärnlöv J, et al. Incidence and determinants of hyperkalemia and hypokalemia in a large healthcare system. Int J Cardiol. 2017;245:277-284.

17. de Boer IH, Gao X, Cleary PA, et al; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Research Group. Albuminuria changes and cardiovascular and renal outcomes in type 1 diabetes: The DCCT/EDIC study. Clin J Am Soc Nephrol. 2016;11:1969-1977.

18. Sumida K, Molnar MZ, Potukuchi PK, et al. Changes in albuminuria and subsequent risk of incident kidney disease. Clin J Am Soc Nephrol. 2017;12:1941-1949.

19. Borch-Johnsen K, Wenzel H, Viberti GC, et al. Is screening and intervention for microalbuminuria worthwhile in patient with insulin dependent diabetes? BMJ. 1993;306:1722-1725.

20. KDOQI. KDOQI clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Am J Kidney Dis. 2007;49(2 suppl 2):S12-154.

21. Bakris GL. Moderately increased albuminuria (microalbuminuria) in type 1 diabetes mellitus. UpToDate. Updated December 3, 2019. Accessed January 5, 2021. https://www.uptodate.com/contents/moderately-increased-albuminuria-microalbuminuria-in-type-1-diabetes-mellitus

22. Delanaye P, Glassock RJ, Pottel H, et al. An age-calibrated definition of chronic kidney disease: rationale and benefits. Clin Biochem Rev. 2016;37:17-26.

23. Levey AS, Stevens LA, Schmid CH, et al; for the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604-612.

24. Wrone EM, Carnethon MR, Palaniappan L, et al; Third National Health and Nutrition Examination Survey. Association of dietary protein intake and microalbuminuria in healthy adults: Third National Health and Nutrition Examination Survey. Am J Kidney Dis. 2003;41:580-587.

25. Knight EL, Stampfer MJ, Hankinson SE, et al. The impact of protein intake on renal function decline in women with normal renal function or mild renal insufficiency. Ann Intern Med. 2003;138:460-467.

26. Bernstein AM, Sun Q, Hu FB, et al. Major dietary protein sources and risk of coronary heart disease in women. Circulation. 2010;122:876-883.

27. de Boer, IH, Bangalore S, Benetos A, et al. Diabetes and hypertension: a position statement by the American Diabetes Association. Diabetes Care. 2017;40:1273-1284.

28. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127-e248.

29. Brenner BM, Cooper ME, de Zeeuw D, et al; RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345:861-869.

30. Lewis EJ, Hunsicker LG, Bain RP, et al. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med. 1993;329:1456-1462.

31. Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet. 2000;355;253-259.

32. Lewis EJ, Hunsicker LG, Clarke WR, et al; Collaborative Study Group. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851-860.

33. Fried LF, Emanuele N, Zhang JH, et al; VA NEPHRON-D Investigators. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013;369:1892-1903.

34. Bakris GL, Agarwal R, Chan JC, et al; Mineralocorticoid Receptor Antagonist Tolerability Study–Diabetic Nephropathy (ARTS-DN) Study Group. Effect of finerenone on albuminuria in patients with diabetic nephropathy: a randomized clinical trial. JAMA. 2015;314:884-894.

35. Filippatos G, Anker SD, Böhm M, et al. Randomized controlled study of finerenone vs. eplerenone in patients with worsening chronic heart failure and diabetes mellitus and/or chronic kidney disease. Eur Heart J. 2016;37:2105-2114.

36. The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes.N Engl J Med. 2008;358:2560-2572.

37. Ismail-Beigi F, Craven T, Banerji MA, et al; ACCORD trial group. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet. 2010;376:419-430.

38. Zoungas S, Chalmers J, Neal B, et al; ADVANCE-ON Collaborative Group. Follow-up of blood-pressure lowering and glucose control in type 2 diabetes. N Engl J Med. 2014;371:1392-1406.

39. Zoungas S, Arima H, Gerstein HC, et al; Collaborators on Trials of Lowering Glucose (CONTROL) group. Effects of intensive glucose control on microvascular outcomes in patients with type 2 diabetes: a meta-analysis of individual participant data from randomised controlled trials. Lancet Diabetes Endocrinol. 2017;5:431-437.

40. Miller ME, Bonds DE, Gerstein HC, et al; ACCORD Investigators. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study. BMJ. 2010;340;b5444.

41. Papademetriou V, Lovato L, Doumas M, et al; ACCORD Study Group. Chronic kidney disease and intensive glycemic control increase cardiovascular risk in patients with type 2 diabetes. Kidney Int. 2015;87:649-659.

42. National Kidney Foundation. KDOQI clinical practice guideline for diabetes and CKD: 2012 Update. Am J Kidney Dis. 2012;60:850-886.

43. Imam TH. Changes in metformin use in chronic kidney disease. Clin Kidney J. 2017;10:301-304.

44. Wanner C, Inzucchi SE, Lachin JM, et al; EMPA-REG OUTCOME Investigators. Empagliflozin and progression of kidney disease in type 2 diabetes. N Engl J Med. 2016;375:323-334.

45. Neal B, Perkovic V, Mahaffey KW, et al; CANVAS Program Collaborative Group. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med. 2017;377:644-657.

46. Marso SP, Daniels GH, Brown-Frandsen K, et al; LEADER Trial Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375:311-322.

47. Mann JFE, Ørsted DD, Brown-Frandsen K, et al; LEADER Steering Committee and Investigators. Liraglutide and renal outcomes in type 2 diabetes. N Engl J Med. 2017;377:839-848.

48. Marso SP, Bain SC, Consoli A, et al; SUSTAIN-6 Investigators. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med. 2016;375:1834-1844.

49. Wanner C, Tonelli M; Kidney Disease: Improving Global Outcomes Lipid Guideline Development Work Group Members. KDIGO clinical practice guideline for lipid management in CKD: summary of recommendation statements and clinical approach to the patient. Kidney Int. 2014;85:1303-1309.

50. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139:e1082-e1143.

51. National Kidney Foundation KDOQI. KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int Suppl. 2012;2:279-335. Accessed January 5, 2021. www.sciencedirect.com/journal/kidney-international-supplements/vol/2/issue/4

52. National Kidney Foundation KDOQI. Evaluation and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). 2010. Accessed January 5, 2021. www.kidney.org/sites/default/files/02-10-390B_LBA_KDOQI_BoneGuide.pdf

53. Smart MA, Dieberg G, Ladhani M, et al. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease. Cochrane Database Syst Rev. 2014;(6):CD007333.

Recommended DKD screening protocol

In all cases of T2D, in cases of T1D of ≥ 5 years’ duration, and in patients with diabetes and comorbid hypertension, perform annual screening for albuminuria, an elevated creatinine level, and a decline in eGFR.

Screen for potential comorbidities of DKD: For example, the risk of cardiovascular disease is significantly elevated in even moderately increased albuminuria.

To confirm the diagnosis of DKD, at least 2 of 3 urine specimens must demonstrate an elevated urinary albumin:creatinine ratio (UACR) over a 3- to 6-month period.²¹ Apart from renal damage, exercise within 24 hours before specimen collection, infection, fever, congestive heart failure, hyperglycemia, menstruation, and hypertension can elevate the UACR.⁶

Levels of the UACR are established as follows²²:

Normal UACR is defined as < 30 milligrams of albumin per gram of creatinine (expressed as “mg/g”).
Increased urinary albumin excretion is defined as ≥ 30 mg/g.
Moderately increased albuminuria, a predictor of potential nephropathy, is the excretion of 30 to 300 mg/g.
Severely increased albuminuria is excretion > 300 mg/g; it is often followed by a gradual decline in eGFR that, without treatment, eventually leads to ESRD.

The rate of decline in eGFR once albuminuria is severely increased is equivalent in T1D and T2D.¹² Without intervention, the time from severely increased albuminuria to ESRD in T1D and T2D averages approximately 6 or 7 years.

Clinical features

DKD is typically a clinical diagnosis seen in patients with longstanding diabetes, albuminuria, retinopathy, or a reduced eGFR in the absence of another primary cause of kidney damage. In patients with T1D and DKD, signs of retinopathy and neuropathy are almost always present at diagnosis, unless a diagnosis is made early in the course of diabetes.¹² Therefore, the presence of retinopathy suggests that diabetes is the likely cause of CKD.

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