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
Nondihydropyridine calcium-channel blockers (CCBs), such as diltiazem and verapamil, have been shown to be more effective then dihydrophyridine CCBs, such as amlodipine and nifedipine, in slowing the progression of renal disease because of their antiproteinuric effects. However, the antiproteinuric effects of nondihydropyridine CCBs are not as strong as those of ACE inhibitors or ARBs, and these drugs do not appear to potentiate the effects of an ACE inhibitor or ARB when used in combination.20
Nondihydropyridine CCBs might be a reasonable alternative in patients who cannot tolerate an ACE inhibitor or an ARB.
Mineralocorticoid receptor antagonists in combination with an ACE inhibitor or ARB have been demonstrated to reduce albuminuria in short-term studies.34,35
Glycemic levels
Studies conducted in patients with T1D, and others in patients with T2D, have shown that tight glycemic control can delay the onset and slow the progression of albuminuria and a decline in the eGFR.10,36-39 The target glycated hemoglobin (A1C) should be < 7% to prevent or slow progression of DKD.40 However, patients with DKD have an increased risk of hypoglycemic events and increased mortality with more intensive glycemic control.40,41 Given those findings, some patients with DKD and significant comorbidities, ESRD, or limited life expectancy might need to have an A1C target set at 8%.6,42
Adjustments to antidiabetes medications in DKD
In patients with stages 3 to 5 DKD, several common antidiabetic medications might need to be adjusted or discontinued because they decrease creatinine clearance.
Continue to: First-generation sulfonylureas
