Type 2 Diabetes and Chronic Kidney Disease: An Opportunity for Pharmacists to Improve Outcomes

Abstract

Chronic kidney disease (CKD) is an important contributor to end-stage kidney disease, cardiovascular disease, and death in people with type 2 diabetes (T2D), but current evidence suggests that diagnosis and treatment are often not optimized. This review examines gaps in care for patients with CKD and how pharmacist interventions can mitigate these gaps. We conducted a PubMed search for published articles reporting on real-world CKD management practice and compared the findings with current recommendations. We find that adherence to guidelines on screening for CKD in patients with T2D is poor with particularly low rates of testing for albuminuria. When CKD is diagnosed, the prescription of recommended heart-kidney protective therapies is underutilized, possibly due to issues around treatment complexity and safety concerns. Cost and access are barriers to the prescription of newer therapies and treatment is dependent on racial, ethnic, and socioeconomic factors. Rates of nephrologist referrals for difficult cases are low in part due to limitations of information and communication between specialties. We believe that pharmacists can play a vital role in improving outcomes for patients with CKD and T2D and support the cost-effective use of healthcare resources through the provision of comprehensive medication management as part of a multidisciplinary team. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across healthcare systems to ensure that comprehensive medication management can be optimally implemented.

Keywords: chronic; diabetes mellitus; heart and kidney protection; multidisciplinary care; pharmacist; renal insufficiency; type 2.

Figure 1

Treatment classes for diabetes, cardiovascular risk, and kidney protection, and lifestyle interventions for the multifactorial management of patients with T2D and CKD [8,18,20,21,22]. Abbreviations used: ACEis, angiotensin-converting enzyme inhibitors; ARBs, angiotensin II receptor blockers; CKD, chronic kidney disease; CVD, cardiovascular disease; GLP-1 RAs, glucagon-like peptide-1 receptor agonists; nsMRAs, nonsteroidal mineralocorticoid receptor antagonists; SGLT-2is, sodium–glucose cotransporter-2 inhibitors; T2D, type 2 diabetes.

Figure 2

The combined effect of albuminuria and eGFR on the risk of cardiovascular events (a) and cardiovascular deaths (b), and kidney events (c), in patients with T2D [17]. The risk is color-coded, with green for values ≤ 1, yellow for values > 1 and ≤2, orange for values > 2 and ≤5, red for values > 5 and ≤10, and burgundy for values > 10. Higher values indicate an increased risk of events. Abbreviations used: eGFR, estimated glomerular filtration rate; GFR, glomerular filtration rate; T2D, type 2 diabetes.

Figure 2

The combined effect of albuminuria and eGFR on the risk of cardiovascular events (a) and cardiovascular deaths (b), and kidney events (c), in patients with T2D [17]. The risk is color-coded, with green for values ≤ 1, yellow for values > 1 and ≤2, orange for values > 2 and ≤5, red for values > 5 and ≤10, and burgundy for values > 10. Higher values indicate an increased risk of events. Abbreviations used: eGFR, estimated glomerular filtration rate; GFR, glomerular filtration rate; T2D, type 2 diabetes.

Figure 3

KDIGO recommendations for serum creatinine and potassium monitoring during ACEi/ARB treatment [18]. Abbreviations used: ACEi, angiotensin-converting enzyme inhibitor; AKI, acute kidney injury; ARB, angiotensin II receptor blocker; GI, gastrointestinal; KDIGO, Kidney Disease: Improving Global Outcomes; NSAID, non-steroidal anti-inflammatory drug. Reproduced from the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, ref. [18] with permission from KDIGO.

Figure 4

Holistic approach for improving outcomes in patients with diabetes and CKD [18]. Icons indicate the following benefits: BP cuff, BP-lowering; glucometer, glucose-lowering; heart, cardioprotection; kidney, kidney protection; scale, weight management. Estimated glomerular filtration rate (eGFR) is presented in units of mL/min/1.73 m². * ACEi or ARB (at maximal tolerated doses) should be first-line therapy for hypertension when albuminuria is present. Otherwise, dihydropyridine calcium channel blocker or diuretic can also be considered; all three classes are often needed to attain BP targets. † Finerenone is currently the only ns-MRA with proven clinical kidney and cardiovascular benefits. Abbreviations used: ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-to-creatinine ratio; ARB, angiotensin II receptor blocker; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CCB, calcium channel blocker; CKD, chronic kidney disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HTN, hypertension; MRA, mineralocorticoid receptor antagonist; ns-MRA, nonsteroidal MRA; PCSK9i, proprotein convertase subtilisin/kexin type 9 inhibitor; RAS, renin–angiotensin system; SGLT-2i, sodium–glucose cotransporter-2 inhibitor; T1D, type 1 diabetes; T2D, type 2 diabetes. Reproduced from the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, ref. [18] with permission from KDIGO.

Figure 5

Key gaps in the management of patients with T2D and CKD and opportunities for pharmacists to address these barriers to optimal care provision [7,23]. Abbreviations used: ACEis, angiotensin-converting enzyme inhibitors; ARBs, angiotensin II receptor blockers; CKD, chronic kidney disease; CMM, comprehensive medication management; GLP-1 RAs, glucagon-like peptide-1 receptor agonists; HCP, healthcare professional; MDT, multidisciplinary team; MRAs, mineralocorticoid receptor antagonists; SGLT-2is, sodium–glucose cotransporter-2 inhibitors; T2D, type 2 diabetes; UACR, urine albumin-to-creatinine ratio.