11. Chronic Kidney Disease and Risk Management: <i>Standards of Medical Care in Diabetes—2022</i>

Draznin, Boris; Aroda, Vanita R.; Bakris, George L.; Benson, Gretchen; Brown, F. C.; Freeman, RaShaye; Green, Jennifer; Huang, Elbert S.; Isaacs, Diana; Kahan, Scott; León, José; Lyons, Sarah K.; Peters, Anne L.; Prahalad, Priya; Reusch, Jane E.B.; Young-Hyman, Deborah Lee; Das, Sandeep R; Kosiborod, Mikhail

doi:10.2337/dc22-s011

Cited by 209 publications

(195 citation statements)

References 110 publications

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“…Routine primary care case finding for CKD with eGFR and uACR should focus on risk conditions, particularly; diabetes, hypertension, cardiovascular disease, and a family history of kidney disease, as recommended by clinical practice guidelines from the American Diabetes Association, 12 Kidney Disease: Improving Global Outcomes, 4 Kidney Disease Outcomes Quality Initiative, 5 and other organizations, in contrast to mass or general population screening. 13 , 14 In recent years in the United States, annual uACR testing is approximately 40% for diabetes and less than 10% for hypertension in national data sets from Medicare, 2 commercial insurance, 2 health systems, 15 and clinical laboratories, 16 supporting the need for interventions to improve targeted albuminuria testing.…”

Section: Primary Care Implementation Of Ckd Testingmentioning

confidence: 99%

“… 17 Testing and recognition of albuminuria will inform the selection of patients who need additional interventions beyond the current ACEi or ARB paradigm, including novel kidney- and cardiovascular-protective therapies, such as sodium-glucose cotransporter-2 inhibitor (SGLT-2i), glucagon-like peptide-1 receptor agonists (GLP1 RA) in type 2 diabetes, and the non-steroidal mineralocorticoid inhibitor (finerenone) in type 2 diabetes. 12 , 17 , 18 Nephrotic albuminuria or the uACR of approximately >2000 mg/g is important for primary clinicians to recognize as suggesting a glomerular disease cause that can be independent of diabetes or hypertension as a comorbidity, 19 requiring nephrology consultation. Primary care education should also review additional diagnostic testing to identify the cause and a possible indication for nephrology consultation for uncertainty on eGFR interpretation.…”

Section: Primary Care Implementation Of Ckd Testingmentioning

confidence: 99%

“… 8 , 20 , 21 Consequences of CKD G3aA1 in seniors include patient medication safety factors, cardiovascular risk, cognitive impairment risks, and risks of major surgery perioperative acute kidney injury, including absence of evidence to support ACEi or ARB and SGLT-2i use for kidney risk indications. 4 , 5 , 12 , 18 , 24 …”

Section: Primary Care Implementation Of Ckd Testingmentioning

confidence: 99%

“… 25 , 26 Similarly, diabetes control should be individualized in a range with less than 7% as the general recommendation. 12 , 24 …”

Section: Primary Care Implementation Of Ckd Testingmentioning

confidence: 99%

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Integrating CKD Into US Primary Care: Bridging the Knowledge and Implementation Gaps

Vassalotti

Boucree

2022

Kidney International Reports

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Chronic kidney disease (CKD) affects 37 million American adults who experience high rates of cardiovascular events and are at risk of kidney failure and mortality. Routine primary care case finding for CKD with estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (uACR) should focus on risk conditions, particularly diabetes, hypertension, and cardiovascular disease, as recommended by clinical practice guidelines. The diagnosis of CKD is associated with many important aspects of care, including patient awareness, patient engagement, and improved implementation of evidence-based interventions. Individualized care that tailors CKD interventions proportional to the adverse outcome risk or the eGFR and uACR heat map is a major challenge for primary CKD care, because the condition is heterogeneous in terms of both the cause and the severity. The coordinated care approach to CKD management is necessary to deploy best practice in chronic disease management that engages the interdisciplinary team. An integrated system supports the timeconstrained primary clinician with CKD registry functions, clinical decision support tools, quality improvement initiatives, and payment model incentives to drive reduction in adverse outcomes and containment of expenditures. A CKD population health strategy can be built to address primary care education and implementation gaps from the perspectives of testing, detection of disease, interventions, and coordinated system-integrated care. Registry function and data monitoring of the burden of CKD, delivery interventions, and outcomes are key features. Implementation of the Race-free 2021 CKD-(Epidemiology Collaboration) EPI eGFR reporting recommendations by engaging local nephrology, administrative, clinical laboratory, and health equity leaders should help drive the population health design strategy and the data assessment.

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Section: Primary Care Implementation Of Ckd Testingmentioning

confidence: 99%

Section: Primary Care Implementation Of Ckd Testingmentioning

confidence: 99%

Section: Primary Care Implementation Of Ckd Testingmentioning

confidence: 99%

“… 25 , 26 Similarly, diabetes control should be individualized in a range with less than 7% as the general recommendation. 12 , 24 …”

Section: Primary Care Implementation Of Ckd Testingmentioning

confidence: 99%

See 2 more Smart Citations

Integrating CKD Into US Primary Care: Bridging the Knowledge and Implementation Gaps

Vassalotti

Boucree

2022

Kidney International Reports

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“…Additional data on the benefits of SGLT2 inhibitors in decompensated heart failure and heart failure with preserved ejection fraction have been included in the updates [ 37 , 38 ]. The updated guideline recommends SGLT2 inhibitors in patients with stage 3 CKD or higher and type 2 diabetes regardless of glycemic control [ 39 ]. For patients with type 2 diabetes and diabetic kidney disease, the use of SGLT2 inhibitors in patients with an estimated glomerular filtration rate of ≥25 mL/min/1.73 m 2 and urinary albumin ≥300 mg/g creatinine is recommended to reduce CKD progression and CVD [ 7 , 9 , 10 , 40 ].…”

Section: Standards Of Medical Care In Diabetes Of the American Diabet...mentioning

confidence: 99%

Recent Updates to Clinical Practice Guidelines for Diabetes Mellitus

Lee

Kim

2022

Endocrinol Metab

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Guidelines for the management of patients with diabetes have become an important part of clinical practice that improve the quality of care and help establish evidence-based medicine in this field. With rapidly accumulating evidence on various aspects of diabetes care, including landmark clinical trials of treatment agents and newer technologies, timely updates of the guidelines capture the most current state of the field and present a consensus. As a leading academic society, the Korean Diabetes Association publishes practice guidelines biennially and the American Diabetes Association does so annually. In this review, we summarize the key changes suggested in the most recent guidelines. Some of the important updates include treatment algorithms emphasizing comorbid conditions such as atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease in the selection of anti-diabetic agents; wider application of continuous glucose monitoring (CGM), insulin pump technologies and indices derived from CGM such as time in range; more active screening of subjects at high-risk of diabetes; and more detailed individualization in diabetes care. Although there are both similarities and differences among guidelines and some uncertainty remains, these updates provide a good approach for many clinical practitioners who are battling with diabetes.

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Modifiability of Composite Cardiovascular Risk Associated With Chronic Kidney Disease in Type 2 Diabetes With Finerenone

et al. 2023

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ImportanceIt is currently unclear whether chronic kidney disease (CKD)–associated cardiovascular risk in type 2 diabetes (T2D) is modifiable.ObjectiveTo examine whether cardiovascular risk can be modified with finerenone in patients with T2D and CKD.Design, Setting, and ParticipantsIncidence rates from Finerenone in Chronic Kidney Disease and Type 2 Diabetes: Combined FIDELIO-DKD and FIGARO-DKD Trial Programme Analysis (FIDELITY), a pooled analysis of 2 phase 3 trials (including patients with CKD and T2D randomly assigned to receive finerenone or placebo) were combined with National Health and Nutrition Examination Survey data to simulate the number of composite cardiovascular events that may be prevented per year with finerenone at a population level. Data were analyzed over 4 years of consecutive National Health and Nutrition Examination Survey data cycles (2015-2016 and 2017-2018).Main Outcomes and MeasuresIncidence rates of cardiovascular events (composite of cardiovascular death, nonfatal stroke, nonfatal myocardial infarction, or hospitalization for heart failure) were estimated over a median of 3.0 years by estimated glomerular filtration rate (eGFR) and albuminuria categories. The outcome was analyzed using Cox proportional hazards models stratified by study, region, eGFR and albuminuria categories at screening, and cardiovascular disease history.ResultsThis subanalysis included a total of 13 026 participants (mean [SD] age, 64.8 [9.5] years; 9088 male [69.8%]). Lower eGFR and higher albuminuria were associated with higher incidences of cardiovascular events. For recipients in the placebo group with an eGFR of 90 or greater, incidence rates per 100 patient-years were 2.38 (95% CI, 1.03-4.29) in those with a urine albumin to creatinine ratio (UACR) less than 300 mg/g and 3.78 (95% CI, 2.91-4.75) in those with UACR of 300 mg/g or greater. In those with eGFR less than 30, incidence rates increased to 6.54 (95% CI, 4.19-9.40) vs 8.74 (95% CI, 6.78-10.93), respectively. In both continuous and categorical models, finerenone was associated with a reduction in composite cardiovascular risk (hazard ratio, 0.86; 95% CI, 0.78-0.95; P = .002) irrespective of eGFR and UACR (P value for interaction = .66). In 6.4 million treatment-eligible individuals (95% CI, 5.4-7.4 million), 1 year of finerenone treatment was simulated to prevent 38 359 cardiovascular events (95% CI, 31 741-44 852), including approximately 14 000 hospitalizations for heart failure, with 66% (25 357 of 38 360) prevented in patients with eGFR of 60 or greater.Conclusions and RelevanceResults of this subanalysis of the FIDELITY analysis suggest that CKD-associated composite cardiovascular risk may be modifiable with finerenone treatment in patients with T2D, those with eGFR of 25 or higher, and those with UACR of 30 mg/g or greater. UACR screening to identify patients with T2D and albuminuria with eGFR of 60 or greater may provide significant opportunities for population benefits.

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11. Chronic Kidney Disease and Risk Management: Standards of Medical Care in Diabetes—2022

Cited by 209 publications

References 110 publications

Integrating CKD Into US Primary Care: Bridging the Knowledge and Implementation Gaps

Integrating CKD Into US Primary Care: Bridging the Knowledge and Implementation Gaps

Recent Updates to Clinical Practice Guidelines for Diabetes Mellitus

Modifiability of Composite Cardiovascular Risk Associated With Chronic Kidney Disease in Type 2 Diabetes With Finerenone

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