The guideline comes at a time when advances in diabetes technology and therapeutics offer new options to manage the large population of patients with diabetes and chronic kidney disease (CKD) at high risk of poor health outcomes.

 

An enlarging base of high-quality evidence from randomized clinical trials is available to evaluate important new treatments offering organ protection, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists.

 

The goal of the new guideline is to provide evidence-based recommendations to optimize the clinical care of people with diabetes and CKD by integrating new options with existing management strategies.

 

In addition, the guideline contains practice points to facilitate implementation when insufficient data are available to make well-justified recommendations or when additional guidance may be useful for clinical application.

 

The guideline covers comprehensive care of patients with diabetes and CKD, glycemic monitoring and targets, lifestyle interventions, antihyperglycemic therapies, and self-management and health systems approaches to management of patients with diabetes and CKD.

 

Kidney International

Volume 98, Issue 4, October 2020, Pages 839-848

 

 

This is the first Kidney Disease: Improving Global Outcomes (KDIGO) Guideline for Diabetes Management in Chronic Kidney Disease. The guideline comes at a pivotal time, with substantial growth in the public health burden of diabetes and chronic kidney disease (CKD), and with recent development of new therapies applicable to this population.^1,2

The goal of the new guideline is to provide evidence-based recommendations and practice points to optimize the clinical care of people with diabetes and CKD by integrating new therapies with existing management approaches. The guideline was written by an international Work Group that included 2 patients and was diverse in clinical expertise, supported by a dedicated Evidence Review Team and professional KDIGO staff. The Work Group aimed to generate a useful resource for clinicians and patients that addressed relevant questions with actionable recommendations, took on controversial topics when there was sufficient evidence to do so, and communicated evidence and recommendations clearly. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was used to evaluate the quality of evidence and strength of recommendations.³ A broad audience was targeted, including all types of clinicians caring for people with diabetes and CKD.

The scope of the new guideline includes patients with type 1 diabetes (T1D), type 2 diabetes (T2D), and all severities of CKD, including patients treated with dialysis or kidney transplantation. Where appropriate, differences in recommendations according to diabetes type or CKD severity are highlighted. The guideline focuses on interventions addressed with rigorous data (especially randomized clinical trials), including lifestyle, pharmacotherapy, and systems interventions. Topics with insufficient evidence evaluating clinical outcomes were not addressed. Readers are referred to related KDIGO guidelines for recommendations on treatment of blood pressure and lipids, and to guidelines from primary care and diabetes organizations for recommendations on prevention and screening of CKD in diabetes.

The new guideline is organized into 5 chapters (Figure 1). Here in this summary, we outline by chapter the 12 evidence-based recommendations, including the general rationale for these recommendations, along with selected practice points. Practice points are opinion-based statements that lack sufficient evidence for a formal recommendation but were considered important by the Work Group to guide clinical care. Readers are referred to the full guideline for a comprehensive description of benefits and harms, level of evidence, factors affecting implementation, additional practice points, and recommendations for future research (https://www.kidney-international.org/issue/S0085-2538(20)X0010-X). In addition, the primary data and meta-analyses used to generate this guideline are available on the MAGICapp platform (https://kdigo.org/guidelines/diabetes-ckd/).

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Figure 1. Recommendations and select practice points from the Kidney Disease: Improving Global Outcomes 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (CKD). eGFR, estimated glomerular filtration rate; SGLT2, sodium–glucose cotransporter-2; T2D, type 2 diabetes.

 

Conclusion

The new KDIGO guideline on diabetes management in CKD offers approaches for evidence-based care of people with diabetes and CKD, supplemented with practice points to inform clinical management and implementation. Evidence will continue to expand, and changes will be needed in the future. In the short term, additional evidence will be incorporated via the MAGICapp platform. It is the hope of the Work Group that clear guidance for the large, high-risk group of patients with diabetes and CKD contained in this guideline can facilitate implementation of better treatments, close the large gap between evidence and current practice, and improve outcomes in this population.