From the Guidelines
The pillars of treatment for diabetic kidney disease focus on comprehensive management to slow disease progression and reduce complications, including glycemic control, blood pressure management, renin-angiotensin system blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and lifestyle modifications, as recommended by the KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease 1. The management of diabetic kidney disease (DKD) requires a multifaceted approach to reduce the risk of kidney disease progression and cardiovascular events.
- Glycemic control should aim for HbA1c targets of 7-7.5% using medications like metformin (500-2000 mg daily), with dose adjustments based on kidney function, as suggested by the ADA/KDIGO consensus report 1.
- Blood pressure should be maintained below 130/80 mmHg using ACE inhibitors like lisinopril (10-40 mg daily) or ARBs such as losartan (50-100 mg daily), which provide both blood pressure control and kidney protection by reducing intraglomerular pressure and proteinuria.
- SGLT2 inhibitors like empagliflozin (10-25 mg daily) or dapagliflozin (10 mg daily) have shown significant kidney protection independent of their glucose-lowering effects, as demonstrated in the KDIGO 2022 clinical practice guideline 1.
- Additional treatments include finerenone (10-20 mg daily), a non-steroidal mineralocorticoid receptor antagonist, and GLP-1 receptor agonists like semaglutide (0.25-1 mg weekly), as recommended by the Mayo Clinic Proceedings article 1.
- Lifestyle modifications are crucial, including dietary sodium restriction (<2 g/day), moderate protein intake (0.8 g/kg/day), weight management, smoking cessation, and regular physical activity, as emphasized in the diabetic kidney disease management field guide for health care professionals 1. Regular monitoring of kidney function, albuminuria, and electrolytes is essential to adjust medications and track disease progression, as highlighted in the KDIGO 2022 clinical practice guideline 1 and the ADA/KDIGO consensus report 1.
From the FDA Drug Label
Losartan may be administered with other antihypertensive agents. These considerations may guide selection of therapy.
- 3 Nephropathy in Type 2 Diabetic Patients Losartan is indicated for the treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g) in patients with type 2 diabetes and a history of hypertension
The pillars of treatment in diabetic kidney disease include:
- Blood pressure control: using antihypertensive agents like losartan to lower blood pressure and reduce the risk of cardiovascular events
- Diabetes management: to control blood sugar levels and slow the progression of kidney disease
- Proteinuria management: to reduce proteinuria and slow the progression of kidney disease Based on the information provided, losartan can be used as part of the treatment for diabetic kidney disease, specifically for patients with type 2 diabetes and a history of hypertension 2.
From the Research
Pillars of Treatment in Diabetic Kidney Disease
The pillars of treatment in diabetic kidney disease (DKD) include:
- Early diagnosis 3, 4
- Improved glycaemic control 3, 4, 5, 6
- Treatment of hypertension 3, 4, 5, 6
- Identification and treatment of associated metabolic bone disease 3
- Identification and effective management of dyslipidaemia and additional cardiovascular risk factors 3, 4, 5, 6
- Use of novel anti-hyperglycaemic agents, such as sodium glucose co-transporter 2 inhibitors and GLP-1 receptor agonists, which have been associated with a reduction in cardiovascular disease and DKD 3, 5, 6
- Blockade of the renin-angiotensin system, which has remained a cornerstone of DKD management 5, 6
- Use of non-steroidal mineralocorticoid receptor antagonists, which have been shown to reduce cardiovascular outcomes and/or mortality in patients with DKD 5, 6
Combination Therapy
Combination therapy, using multiple agents that have been shown to reduce cardiovascular outcomes and/or mortality, is recommended for maximal cardiorenal protection in patients with DKD 5, 6. The four pillars of therapy for the attenuation of residual cardiorenal risk in patients with CKD associated with T2D are:
- Pharmacological blockade of the renin-angiotensin-system (RAS) 6
- Sodium-glucose co-transporter type 2 (SGLT-2) inhibitors 6
- Non-steroidal mineralocorticoid-receptor-antagonist (MRA) finerenone 6
- Glucagon-like peptide-1 receptor agonist (GLP-1RA) semaglutide 6
Safety and Effectiveness of Metformin
Metformin has been found to be more effective than sulfonylureas in reducing all-cause mortality, improving GFR, and reducing the risk of ESRD or death events in patients with diabetic nephropathy 7. Additionally, metformin has been found to be safe compared to sulfonylurea therapy in diabetic nephropathy patients, provided that the contraindications given in the guidelines are strictly adhered to 7.