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Guideline for Diabetes Management in Chronic Kidney Disease

In an update of the 2020 Kidney Disease: Improving Global Outcomes (KDIGO) guideline, key recommendations on diabetes management in patients with chronic kidney diseases cover comprehensive care, glycemic monitoring and targets, lifestyle interventions, antihyperglycemic therapies, and educational and integrated care approaches to management.

The KDIGO guideline update is based upon literature searches conducted in Dec. 2021, limiting the searches to randomized controlled trials only, and updated in Feb. 2022 at the time of the public review. The evidence synthesis and meta-analysis methods undertaken for the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease were followed for the 2022 guideline update.

Summarizing the guideline’s 13 recommendations and 52 practice points, authors from the KDIGO Work Group write: “A focus on preserving kidney function and maintaining well-being is recommended using a layered approach to care, starting with a foundation of lifestyle interventions, self-management, and first-line pharmacotherapy (such as sodium–glucose cotransporter-2 inhibitors) demonstrated to improve clinical outcomes. To this are added additional drugs with heart and kidney protection, such as glucagon-like peptide-1 receptor agonists and nonsteroidal mineralocorticoid receptor antagonists, and interventions to control risk factors for CKD progression and cardiovascular events, such as blood pressure, glycemia, and lipids.”

Editorial: “At a societal level, structural inequalities will impede adoption of this new guideline,” editorialists write. “The 2022 and 2020 KDIGO guidelines focus only on clinician- and health system–level interventions to increase adoption of these drugs. They recommend that policymakers and institutional leaders implement team-based, integrated care focused on risk evaluation and patient empowerment. Indeed, team-based care, shared decision making, and multimorbid disease management are cornerstones of good health outcomes. However, clinician- and health system–level interventions, although important, are not enough. Team-based, integrated care must be supported by payment models and workforce development that are financially sustainable and allow clinicians to provide high-quality care. Equitable care also requires that all patients, regardless of race, location, or insurance, have timely, affordable access to well-informed clinicians and medications. Without equitable implementation of the KDIGO 2022 guidelines, there is a potential that clinical practice variation will increase and widen health inequities for minoritized people with CKD and diabetes. As part of their mission, professional societies should also make recommendations for pharmacy formularies, insurance companies, and governments regarding equitable access to evidence-based care. Overall, the KDIGO 2022 guidelines provide important support for widespread expansion and adoption of SGLT2 inhibitors, nonsteroidal MRAs, and GLP-1 RAs—the impact of which will be determined by how effective the health care system and its patients and clinicians are at overcoming individual and structural barriers.”

Source: Annals of Internal Medicine