From the Guidelines
Chronic Kidney Disease (CKD) is a common microvascular complication in patients with both type 1 and type 2 diabetes, defined as persistent albuminuria or persistent reduction in estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m², or both, for at least 3 months, as noted in a recent study 1.
Definition and Diagnosis
CKD is characterized by a gradual loss of kidney function over time, and its diagnosis is based on signs, symptoms, and laboratory values, including urinary albumin excretion and eGFR levels 1.
- The terms diabetic kidney disease (DKD) and diabetic nephropathy are frequently used interchangeably, but there are important differences between these terms, with DKD being a clinical diagnosis and diabetic nephropathy being a tissue diagnosis 1.
- Estimates suggest that approximately 40% of patients with type 2 diabetes have CKD (stages 1 to 4), with more than half of whom having moderate to severe disease (stage 3 and stage 4) 1.
Management and Treatment
Management of CKD focuses on slowing progression and treating complications, with blood pressure control being essential, and the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists offering unprecedented opportunities to reduce the risk for progression of kidney disease and the risk of death 1.
- An integrated approach to patient care with a multidisciplinary focus can help achieve the necessary shift in clinical care of patients with CKD, as highlighted in a recent review 1.
- The American Diabetes Association, the Kidney Disease: Improving Global Outcomes, and the European Association for the Study of Diabetes now recommend the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists for patients with DKD to provide both kidney and cardiovascular protective benefits 1.
From the Research
Definition and Classification of Chronic Kidney Disease (CKD)
- Chronic kidney disease (CKD) is defined as either kidney damage or an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m2 for more than 3 months 2
- Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies 2
- CKD is classified as stage 1 to 5 on the basis of eGFR 2
Prevalence and Association with Hypertension
- CKD is recognized as a worldwide epidemic, and hypertension commonly coexists with CKD 3
- The prevalence of hypertension is progressively increasing as kidney function declines 3
- CKD patients frequently present non-dipper and salt-sensitive type hypertension, which is a powerful predictor for both CKD and cardiovascular disease (CVD) 4
Blood Pressure Control in CKD Patients
- The target blood pressure for CKD patients is less than 130/80 mmHg, or 125/75 mmHg if the amount of urinary protein is more than 1 g/day 4, 2
- Blood pressure control using the renin-angiotensin system (RAS) inhibitor, such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), is superior to other classes of antihypertensive agents in reducing the amount of urinary protein and preserving renal function 4, 2
- The updated guideline by Kidney Disease: Improving Global Outcomes (KDIGO) in 2021 suggests a systolic BP target of <120 mm Hg for most individuals with CKD not receiving dialysis, based on standardized measurements 5
Treatment Options for CKD Patients
- ACEIs and ARBs are the first-line agents for controlling blood pressure in CKD patients, and have been shown to have renoprotective effects in addition to their ability to control blood pressure 3, 2
- Other classes of antihypertensive agents, such as diuretics and calcium channel blockers, may be used in addition to ACEIs and ARBs to achieve the target blood pressure 3, 2
- Mineralocorticoid receptor blockade has been studied as a novel approach to further slow down CKD progression, and may further reduce albuminuria in diabetic nephropathy 6