New Section on Chronic Kidney Disease Risk Management Added to ADA Standard of Care Guidelines

In their updated 2022 guidelines, the American Diabetes Association (ADA) added a section directed at the prevention and management of chronic kidney disease (CKD) for patients with diabetes.

Section 11 of the guidelines made a number of screening and treatment recommendations for patients with diabetes who have or are at an increased risk of developing CKD. The section also offers insights into the clinical data that supports the recommendations and offers informational support for clinicians to help monitor and manage CKD in the diabetes population.

“Based on some of the recent studies and new treatments that are available, a couple of things [became clear]. One, we know that chronic kidney disease continues to be a huge issue and it's under diagnosed and under treated. And second, we now have new treatments that can really lower the risk of chronic kidney disease and particularly the progression,” said Robert Gabbay, MD, PhD, chief scientific and medical officer at the ADA, in an interview.

CKD is diagnosed in between 20% and 40% of patients with diabetes. Diabetic kidney disease often manifests after a patient has had type 1 diabetes for 10 years but can also be present at diagnosis in patients with type 2 diabetes. If untreated, CKD can progress to end-stage renal disease, requiring patients to receive regular hemodialysis therapy or a kidney transplantation.

Additionally, the presence of CKD in patients with type 1 or type 2 diabetes significantly increases their risk of cardiovascular events as well as health care costs. People with diabetes are also at a higher risk of experiencing acute kidney injury compared to people without diabetes, with risk factors including preexisting CKD, the use of medications that alter renal blood flow and intrarenal hemodynamics, and the use of medications that cause kidney injury, such as nonsteroidal anti-inflammatory drugs.

According to Gabbay, nephrologists were included into the group that helped design the standards and the discussions in the broader professional practice committee.

Within Section 11, the ADA said that treatment with finerenone (Kerendia) is recommended to reduce risks CKD progression and cardiovascular events in patients who are at an increased risk or are unable to use a sodium-glucose cotransporter 2 inhibitor. Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, was approved by the FDA in July 2021. The drug has been shown to provide cardiovascular benefits in patients with mild to moderate kidney disease and type 2 diabetes in clinical trials.

“We’re driven by improving the lives of people affected by diabetes. And so, the underlying reason for doing this standard of care is really to help guide clinicians in the best care of their patients. And finerenone is a new treatment that can significantly improve outcomes for people with diabetes. So, our hope is that these standards help to bring the attention to clinicians about this new treatment option,” Gabbay explained.

Some the other recommendations on the list included:

• Annual assessments of urinary albumin and estimate glomerular filtration rates in patients with type 1 diabetes with a disease duration of at least 5 years and in all patients with type 2 diabetes
• Refraining from discontinuation of renin-angiotensin system blockade for minor increases in serum creatinine in the absence of volume depletion
• Use of an ACE inhibitor or angiotensin receptor blocker for nonpregnant patients with diabetes and hypertension and modestly elevated urinary albumin-to-creatinine ratio
• Periodic monitor of serum creatinine and potassium levels for changes when patients are treated with ACE inhibitors, angiotensin receptor blockers, or diuretics
• Referral of patients to nephrologists if they have an estimated glomerular filtration rate of less than 30 mL/min/1.73m²
• Prompt referral to nephrologists when uncertain about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease.

Reference

The American Diabetes Association. 11. Chronic kidney disease and risk management: Standards of medical care in diabetes—2022. Diabetes Care. 2022;45(1):S175–S184. doi:10.2337/dc22-S011