Tactics to prevent or slow progression of CKD in patients with diabetes
Annual screening of urinary parameters, ongoing clinical vigilance, and proper medical therapy can help to keep declining renal function at bay.
PRACTICE RECOMMENDATIONS
› Screen patients with diabetes annually for diabetic kidney disease with measurement of urinary albumin and the estimated glomerular filtration rate. B
› Optimize blood glucose and blood pressure control in patients with diabetes to prevent or delay progression to diabetic kidney disease. A
› Treat hypertensive patients with diabetes and stages 1 to 4 chronic kidney disease with an angiotensin-converting enzyme inhibitor or angiotensin II-receptor blocker as a first-line antihypertensive, absent contraindications. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) have renoprotective benefits. These agents are recommended as first-line medications for patients with diabetes, hypertension, and an eGFR < 60 mL/min/1.73 m2 and a UACR > 300 mg/g.29-31 Evidence also supports their use when the UACR is 30 to 299 mg/g.
Studies have shown that, in patients with DKD, ACE inhibitors and ARBs can slow the progression of renal disease.29,30,32 There is no difference between ACE inhibitors and ARBs in their effectiveness for preventing progression of DKD.6 There is no added benefit in combining an ACE inhibitor and an ARB33; notably, combination ACE inhibitor and ARB therapy can increase the risk of adverse events, such as hyperkalemia and acute kidney injury, especially in patients with DKD.33
There is no evidence for starting an ACE inhibitor or ARB to prevent CKD in patients with diabetes who are not hypertensive.5
ACE inhibitors and ARBs should be used with caution in women of childbearing age, who should use a reliable form of contraception if taking one of these drugs.
Diuretics. Thiazide-type and loop diuretics might potentiate the positive effects of ACE inhibitors and ARBs. KDOQI guidelines recommend that, in patients who require a second agent to control BP, a diuretic should be considered in combination with an ACE inhibitor or an ARB.20 A loop diuretic is preferred if the eGFR is < 30 mL/min/1.73 m2.
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