KDIGO 2022 Clinical Practice Guideline: Management Updates for Diabetes, CKD

In an update from the 2020 guideline, the Kidney Disease: Improving Global Outcomes (KDIGO) Work Group released the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (CKD).

This updated guideline includes 13 recommendations and 52 practice points for clinicians treating patients with type 2 diabetes (T2D) and CKD, as focused on in a synopsis published in Annals of Internal Medicine.

Specifically, the synopsis covered key recommendations pertinent to comprehensive care, glycemic monitoring and targets, lifestyle interventions, antihyperglycemic therapies, and educational and integrated care approaches to management.

When it comes to comprehensive care, lifestyle intervention was a key feature in the updated recommendations, with the 2022 guideline including therapies that have demonstrated improvement in cardiovascular and kidney outcomes in patients with T2D and CKD.

SGLT2 inhibitors were specifically noted as the preferred first-line pharmacologic therapy for patients with the 2 conditions regardless of glycemic control, adding other glucose-lowering therapies to the SGLT2 inhibitors to maintain individualized glycemic targets.

The updated guideline also adjusted SGLT2 inhibitor recommendations for patients with CKD based on estimated glomerular filtration rate (eGFR). While the 2020 guideline recommended SGLT2 inhibitors for patients with an eGFR of at least 30 mL/min/ 1.73 m2, the 2022 guideline now recommends initiating the therapy in patients with an eGFR of at least 20 mL/min/1.73 m2. This adjustment was made based on findings from 7 large trials examining cardiovascular and kidney effects of several SGLT2 inhibitors published since the 2020 guideline.

“Furthermore, given the strong evidence in diverse patient populations with CKD, including those without diabetes, this topic was moved from Chapter 4 (Glucose-Lowering Therapies in Patients With T2D and CKD) to Chapter 1 (Comprehensive Care in Patients With Diabetes and CKD),” the authors added. “This change acknowledges the evidence that benefit of SGLT2 inhibitors is independent of glycemic control and the recommendation to use SGLT2 inhibitors for organ protection (heart and kidney) in patients with CKD.”

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) continue to be the recommended second-line drug class for glucose lowering in T2D and CKD. One trial published since 2020 was added to the evidence linking GLP-1 RAs to cardiovascular benefits, and contributed to the hypothesis that GLP-1 RAs may also improve kidney outcomes. A new practice point highlighting potential advantages of weight loss with GLP-1 RAs was also added to the 2022 guideline.

Finally, the KDIGO 2022 Clinical Practice Guideline added a new section on the use of mineralocorticoid receptor antagonists (MRAs).

MRAs reduce residual proteinuria in patients receiving renin-angiotensin system inhibitors. While multiple smaller clinical trials demonstrated antiproteinuric effects of steroidal MRAs without development of hyperkalemia, these benefits of these treatments on CKD progression has not yet been made clear.

“With new therapies that can reduce progression of CKD and diminish the burden of cardiovascular disease, including heart failure, health care providers should focus on preserving kidney function and maintaining well-being rather than replacing kidney function,” the synopsis authors wrote.

They added that, while these updated recommendations have potential to change the natural history of diabetes CKD, barriers at the patient, clinician, and health system levels may limit this potential.

“Implementation of evidence-based treatments is now critical to improving the outcomes of patients living with diabetes and CKD,” the authors concluded.

Reference

Navaneethan SD, Zoungas S, Caramori ML, et al. Diabetes management in chronic kidney disease: synopsis of the KDIGO 2022 clinical practice guideline update. Ann Intern Med. Published online January 9, 2023. doi:10.7326/M22-2904