ADA 81st Symposium: Evidence-Based Guidelines For Diabetes and Chronic Kidney Disease

Diabetes is the leading cause of chronic kidney disease (CKD) due to microvascular damage to the renal blood vessels and new ADA guidelines recommend using SLGT2is for patients with both conditions.

Recent trials have shown that sodium-glucose transporter 2 (SGLT2) inhibitors, a medication class that treats patients with type 2 diabetes, also provide renal protection. Now that this information has become available, the new American Diabetes Association (ADA) guidelines recommend using SLGT2 inhibitors in diabetes and chronic kidney disease (CKD) patients.

The new guidelines also recommend updated lifestyle interventions, specific antihyperglycemic therapies, comprehensive care, glycemic monitoring and targets, and approaches to managing patients with diabetes and CKD.

Starting with lifestyle intervention recommendations, patients with diabetes and CKD should consume a personalized diet plan. The diet should be high in plant-based proteins, nuts, unsaturated fats, vegetables, whole grains, fiber, legumes, and fruits. The diet needs to be low in processed carbohydrates, sweetened drinks, and processed meats. The breakdown of the plate should be; half is fruit and vegetables, while a quarter is protein, and a quarter is whole grains or starchy vegetables. The specific protein intake suggestion is 0.8g of protein/kg for those with both diabetes and CKD that are not on dialysis. Dairy, milk, yogurt, and cheese are considered animal proteins as are meat, poultry, seafood, eggs, and fish.

The recommendation for sodium intake is <2g of sodium per day.  The evidence is strong that reducing salt intake will decrease systolic and diastolic blood pressure. There are many ways to reduce sodium. Salt-free spices and fresh herbs can add flavor instead; buying new food and preparing it at home rather than eating out, buying unsalted butter, and cutting out salty sauces and condiments are examples of reducing sodium.

Patients with diabetes and CKD should do moderate-intensity physical activity for 150 minutes per week or to the level they can tolerate. Biking, swimming, brisk walking, and yoga are various examples of moderate-intensity physical activities. Accompanying physical activity, nutrition modifications, and weight loss (if needed) as first-line therapy for patients with type 2 diabetes (T2DM) and CKD is metformin and a sodium-glucose transport 2 inhibitor (SGLT2i). If the patient’s eGFR is below 45, then reduce the dose of metformin. If the patient’s EGR is less than 30, discontinue the metformin and start the SGLT2 inhibitor. If a medication needs to be added to the duo of metformin and the SGLT2 inhibitor, the recommendation is to add a long-acting GLP-1 receptor agonist (GLP-1RA) unless contraindicated. The GLP-1RA should have cardiovascular benefits and should be titrated up slowly from a low dose. The GLP-1RA should not be taken if the patient is on a dipeptidyl peptidase-4 (DPP-4 inhibitor).

To select a glucose-lowering agent besides metformin and SGLT2i, the ADA has an algorithm where cost, comorbidities, eGFR,  and ASCVD risk are taken into consideration, as well as potential unwanted side effects.

The ADA recommends a self-managed educational program be implemented for patients with both CKD and diabetes.  This self-management shines a light on the shift in the ADA to a patient-centered model.

Practice Pearls:

• Patients with CKD should be put on an SGLT2i dependent on whether the patient has diabetes.
• Patient care needs to be individualized with comorbidities and patient preferences considered.
• Patients with diabetes and CKD should do moderate-intensity physical activity for 150 minutes per week or to the level they can tolerate.

Sadusky, Tami. “Living With Diabetes and Chronic Kidney Disease.” American Diabetes Association (ADA) Virtual 81^st Scientific Sessions. (Requires ADA Symposium login.) June 25. 2021, https://www.ada2021.org

Ashley Ball, PharmD Candidate, LECOM-School of Pharmacy