Kidney Disease Improving Global Outcomes (KDIGO) has come up with guidelines to manage diabetes in CKD patients. This article will highlight the important recommendations from the guidelines.

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As we know India is often referred to as the diabetic capital of the world, and the complications associated with it are also increasing with every passing day. Diabetic nephropathy is one of the most common complications faced by clinicians among diabetic patients.

Clinicians should use this chart as a reference to classify diabetic nephropathy patients. Calculating eGFR for diabetic patients as per their age and creatinine should be followed in clinical practice to avoid missing patients with early stages of diabetic nephropathy.

KDIGO Classification of CKD using GFR and ACR categories chart

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1. Comprehensive care in patients with diabetes and chronic kidney disease

Patients with diabetes and CKD should be treated with a comprehensive strategy to reduce the risks of kidney disease progression and CVD.

1. This includes lifestyle modification like a healthy diet, regular exercise, smoking cessation and weight management.
2. The first-line therapies should be initiated wherever indicated for the control of diabetes, hypertension, and dyslipidemia.
3. Additional drugs with proven kidney and heart protection as guided by residual risk assessment.

As per recommendation the treatment with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) be initiated in patients with diabetes, hypertension, and albuminuria, and these medications are titrated to the highest approved dose that is tolerated.

1. ACEi or ARB may be considered for diabetic patients with albuminuria with normal blood pressure.
2. Regular monitoring of BP, Serum Creatinine and Serum potassium within 2-4 weeks of initiation or increase in the dose of RAS blockers. Stop ACEi or ARB once the creatinine rises by more than 30% within 4 weeks following initiation or increase in dose.
3. Avoid these drugs in pregnant women or advise contraception in women receiving ACEi or ARB.
4. Never combine ACEi and ARB together, or ACEi or ARB with a direct renin inhibitor.
5. For hyperkalemia associated with the use of ACEi or ARB, the drug should not be stopped rather measures to reduce with the use of potassium binders, moderate potassium intake or the use of diuretics should be considered.

As per recommendation patients with type 2 diabetes and CKD with eGFR >20ml/min/per 1.73 m2 should be treated with SGLT2i.

1. SGLT2i have safety and benefit in CKD patients, even without diabetes. In diabetic patients, SGLT2i can be added to the current treatment regimen considering eGFR >20.
2. Withhold SGLT2i during times of prolonged fasting, surgery or critical medical illness.
3. Patients should be counselled about follow-up on volume status after drug initiation, and genitourinary infections associated with it.
4. A reversible decrease in the eGFR with the commencement of SGLT2i treatment may occur and is generally not an indication to discontinue therapy.
5. Once the SGLT2i is started it is reasonable to continue even if eGFR falls below 20 unless it is not tolerated or kidney replacement therapy is initiated.
6. SGLT2i should not be used in kidney transplant patients.

As per recommendation nonsteroidal mineralocorticoid receptor antagonist (nsMRA) with proven kidney or cardiovascular benefit for patients with T2D, an eGFR ≥25 ml/min per 1.73 m2, normal serum potassium concentration, and albuminuria (≥30 mg/g [≥ 3mg/mmol]) despite a maximum tolerated dose of RAS inhibitor (RASi) should be initiated.

1. Finerenone should be started at 10mg per day if eGFR is in the range of 25 -59, and 20mg per day if it is more than 60. K+ should be monitored 1 month after starting and then every 4 months. If the patient develops hyperkalemia finer enone should be stopped until K+ <5.0 mmol/l.
2. A steroidal MRA should be used for the treatment of heart failure, hyperaldosteronism, or refractory hypertension, but may cause hyperkalemia or a reversible decline in glomerular filtration, particularly among patients with a low GFR.

As per recommendation patients with diabetes and CKD who use tobacco to quit tobacco products.

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2. Glycemic monitoring and targets in patients with diabetes and CKD

As per recommendation, haemoglobin A1c (HbA1c ) should be monitored for known glycemic control in patients with diabetes and CKD. An individualised HbA1c target ranges from <6.5 to <8.0 in patients with diabetes and CKD not treated with dialysis.

1. HbA1c twice per year is reasonable for patients with controlled diabetes and may be measured 4 times per year if the glycemic target is not met.
2. Accuracy and precision of HbA1c measurement decline with advanced CKD (G4-G5), particularly among patients treated by dialysis, in whom HbA1c measurements have low reliability.
3. Continuous glucose monitoring (CGM) can be used for patients in whom HbA1c is not concordant with directly measured blood glucose levels.
4. SMGB and CGM use may help to prevent hypoglycemia and improve glycemic control.
5. CGM metrics, such as time in range and time in hypoglycemia, may be considered alternatives to HbA1c for defining glycemic targets in some patients.

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3. Lifestyle intervention and recommendations in patients with diabetes and CKD

1. A protein intake of 0.8 g of protein/kg (weight)/d for those with diabetes and CKD not treated with dialysis. Patients on dialysis and particularly peritoneal dialysis should consume between 1.0 and 1.2g protein/kg weight/ day.
2. Sodium intake is <2 g of sodium per day (or <90 mmol of sodium per day, or <5 g of sodium chloride per day) in patients with diabetes and CKD.
3. Patients with diabetes and CKD be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with their cardiovascular and physical tolerance.
4. Patients with diabetes and CKD should consume a diet high in vegetables, fruits, whole grains, fibre, legumes, plant-based proteins, unsaturated fats, and nuts; and lower in processed meats, refined carbohydrates, and sweetened beverages.

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4. Glucose lowering therapies in patients with diabetes and CKD

As per recommendation the patients with diabetes and CKD with eGFR>30 should be started on metformin.

1. Patients with kidney transplants with type 2 diabetes and eGFR>30 should be treated with metformin as per the recommendation.
2. Increase the frequency of monitoring when eGFR is <60 in patients treated with metformin.
3. The dose of metformin should be adjusted once eGFR is <45 and should be stopped in patients with eGFR<30.
4. Vitamin B12 levels should be checked once the patients are treated with metformin for more than 4 years.

The recommendation suggested that in patients with T2D and CKD who have not achieved individualised glycemic targets despite the use of metformin and SGLT2i treatment, or who are unable to use those medications, we recommend a long-acting GLP-1 RA.

1. The GLP-1 RA should be selected on basis of documented cardiovascular benefits.
2. Start with a lower dose of GLP-1 RA to minimise the gastrointestinal side effects.
3. GLP-1 RA should not be used with dipeptidyl peptidase-4(DPP-4) inhibitors.
4. GLP-1 RA may be preferentially used in patients with obesity, T2D, and CKD to promote intentional weight loss.

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5. Approaches to management of patients with diabetes and CKD

As per recommendation, a structured self-management educational program is implemented for the care of people with diabetes and CKD.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Hitesh Saraogi is a diabetologist and physician at Dhanvantari Hospital, Raj Nagar Extension, Ghaziabad.