Kidney Disease: Improving Global Outcomes Summit Recommendations on Implementation of Diabetes Management in CKD: From Primary to Data-Driven Collaborative Care

Abstract

Type 2 diabetes and chronic kidney disease (CKD) are preventable and treatable. Their silent and progressive clinical course calls for structured assessment with timely feedback to patients and care providers for activating decision-making. Apart from CKD, patients with diabetes can have complications affecting multiple organs, notably the cardiovascular system, eyes, and feet. International practice guidelines recommend annual assessment of the eyes, feet, blood, and urine to detect silent complications and measure cardiovascular-kidney-metabolic (CKM) risk factors to ensure early intervention, including treatment to multiple targets and use of organ-protective drugs. In this report, we highlight the barriers and gaps in the implementation of practice guidelines in managing diabetes in CKD with proposed solutions to overcome such barriers. By improving the practice environment and workflow, nurses can be trained to perform protocol-guided evaluation under medical supervision. The systematic data collection enables physicians to make timely decisions, including drug prescriptions and referrals to other specialists to promote collaborative care, whereas nurses can use the personalized data to empower patient self-management and improve health literacy. This ongoing data collection will form a register to align payers, providers, and patients in delivering data-driven and value-based care with the creation of real-world evidence to verify treatment effectiveness and identify care gaps while providing on-the-job training. When accompanied by a biobank, the ongoing collection and analysis of this multidimensional data will refine diagnosis, classification, prognosis, and treatment in pursuit of precision medicine.

Keywords: CKD; KDIGO; collaborative care; diabetes; primary care; specialist care.

Figure 1

A concise action framework to enhance early detection of chronic kidney disease (CKD) in T2D in the primary care setting, with considerations given to availability and scalability of resources. A diagnosis of CKD can be made in the presence of either eGFR < 60 ml/min per 1.73 m² or albuminuria > 3 mg/mmol (or 30 mg/g) for at least 3 consecutive months.^aManagement of CKD and type 2 diabetes is based on the KDIGO 2022 Clinical Practice Diabetes Guideline. BP, blood pressure; eGFR, estimated glomerular filtration rate; HbA_1c, glycated hemoglobin; KDIGO, Kidney Disease: Improving Global Outcomes; NCD, non-communicable disease; NS-MRA, nonsteroidal mineralocorticoid receptor antagonist; POC, point-of-care; RAS, renin-angiotensin system; SGLT2, sodium–glucose cotransporter-2; T2D, type 2 diabetes; UACR, urinary albumin-to-creatinine ratio.

Figure 2

A joint consensus statement by the American Diabetes Association and KDIGO on the medical treatment of patients with T2D in CKD in line with the proposed BARS or BAR-4S concepts (Figure 1). In patients with CKD defined by persistent eGFR < 60 ml/min per 1.73 m² or persistent uACR > 30 mg/g (or 3 mg/mmol) or evidence of kidney damage, metformin and SGLT2i are the preferred organ protective drugs and can be prescribed at eGFR 30 and 20 ml/min per 1.73 m² or higher, respectively for cardiovascular-kidney protections. GLP-1 RA can be considered as an additional risk-based therapy, especially in the presence of obesity and suboptimal control of glycemia. Patients with CKD should be protected by a RASi at the maximally tolerated dose followed^∗ by ns-MRA if there is persistent uACR > 30 mg/g (or 3 mg/mmol) despite being on SGLT2i or RASi (provided eGFR > 20 ml/min per 1.73 m² with normal serum potassium level). ^†Finerenone is currently the only ns-MRA with proven clinical kidney and cardiovascular benefits. Given the heterogeneity of risk factors and treatment responses, treatment should be individualized to achieve the dual goals of optimal control of multiple risk factors (i.e., blood pressure, blood lipids, blood glucose, and obesity) and organ protection. Icons presented indicate the following benefits: blood pressure cuff = blood pressure–lowering; glucometer = glucose-lowering; heart = heart protection; kidney = kidney protection; scale = weight management. ASCVD, atherosclerotic cardiovascular disease; 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; KDIGO, Kidney Disease: Improving Global Outcomes; ns-MRA, nonsteroidal mineralocorticoid receptor antagonist; PCSK9i, proprotein convertase subtilisin/kexin type 9 inhibitor; RASi, renin-angiotensin system inhibitor; SGLT2i, sodium-glucose cotransporter-2 inhibitor; T1D, type 1 diabetes; T2D, type 2 diabetes; uACR, urinary albumin-to-creatinine ratio.

Figure 3

Implementation of data-driven Kidney Protection Plan (KPP) targeting the system, patients, and providers with the aim of providing regular structured assessment. A multidisciplinary approach with feedback to patients and providers for promoting early control of multiple risk factors (i.e., hyperglycemia, high blood pressure, dyslipidemia, and overweight), use of organ-protective drugs, and patient empowerment with ongoing data collection is proposed to align decision making by patients, providers, and payors. Guidance above was adapted from KDIGO 2022, de Boer et al., Chan et al., KDIGO 2021, Baigent et al., Bi et al. ∗HbA1c goal should be individualized taking into consideration age at diagnosis, expected disease duration, risk of hypoglycemia, comorbidities, frailty, life expectancy, cognitive function and social support. EMR, electronic medical record; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HbA_1c, glycated hemoglobin; nsMRA, nonsteroidal mineralocorticoid receptor antagonist; RASi, renin-angiotensin system inhibitor; SBP, systolic blood pressure; SGLT2i, sodium-glucose cotransporter-2 inhibitor.