The 2021-2022 position of Brazilian Diabetes Society on diabetic kidney disease (DKD) management: an evidence-based guideline to clinical practice. Screening and treatment of hyperglycemia, arterial hypertension, and dyslipidemia in the patient with DKD

Abstract

Background: Diabetic kidney disease is the leading cause of end-stage renal disease and is associated with increased morbidity and mortality. This review is an authorized literal translation of part of the Brazilian Diabetes Society (SBD) Guidelines 2021-2022. This evidence-based guideline provides guidance on the correct management of Diabetic Kidney Disease (DKD) in clinical practice.

Methods: The methodology was published elsewhere in previous SBD guidelines and was approved by the internal institutional Steering Committee for publication. Briefly, the Brazilian Diabetes Society indicated 14 experts to constitute the Central Committee, designed to regulate methodology, review the manuscripts, and make judgments on degrees of recommendations and levels of evidence. SBD Renal Disease Department drafted the manuscript selecting key clinical questions to make a narrative review using MEDLINE via PubMed, with the best evidence available including high-quality clinical trials, metanalysis, and large observational studies related to DKD diagnosis and treatment, by using the MeSH terms [diabetes], [type 2 diabetes], [type 1 diabetes] and [chronic kidney disease].

Results: The extensive review of the literature made by the 14 members of the Central Committee defined 24 recommendations. Three levels of evidence were considered: A. Data from more than 1 randomized clinical trial or 1 metanalysis of randomized clinical trials with low heterogeneity (I² < 40%). B. Data from metanalysis, including large observational studies, a single randomized clinical trial, or a pre-specified subgroup analysis. C: Data from small or non-randomized studies, exploratory analyses, or consensus of expert opinion. The degree of recommendation was obtained based on a poll sent to the panelists, using the following criteria: Grade I: when more than 90% of agreement; Grade IIa 75-89% of agreement; IIb 50-74% of agreement, and III, when most of the panelist recommends against a defined treatment.

Conclusions: To prevent or at least postpone the advanced stages of DKD with the associated cardiovascular complications, intensive glycemic and blood pressure control are required, as well as the use of renin-angiotensin-aldosterone system blocker agents such as ARB, ACEI, and MRA. Recently, SGLT2 inhibitors and GLP1 receptor agonists have been added to the therapeutic arsenal, with well-proven benefits regarding kidney protection and patients' survival.

Keywords: Diabetes mellitus; Diabetic kidney disease; Diabetic nephropathy; Management; Treatment.

Fig. 1

Stages of chronic kidney disease according to glomerular filtration rate (GFR) and albuminuria levels and risk rating for progression to end-stage kidney disease. Source: Adapted from KDIGO [11]

Fig. 2

Algorithm for the treatment of hyperglycemia in patients with T2DM and DKD with GFR between 30 and 60 mL/min/1.73 m² or between 30 and 90 mL/min/1.73 m² with albuminuria. AD: Oral antidiabetic. Source: Adapted from Bertoluci et al. [51]. SGLT2: sodium-glucose cotransporter 2; GLP1: glucagon-like peptide 1

Fig. 3

Management of hyperglycemia in severe DKD. Source: Adapted from Bertoluci et al. [64]. *Dose adjustment required, except for linagliptin. **Only if GFR > 15 mL/min/1.73 m²

Fig. 4

Recommendation for checking capillary blood glucose on days with and without dialysis. Adapted from Escott et al. [75]