From the Guidelines
Hyperglycemia management should focus on tight glycemic control with metformin and an SGLT2 inhibitor as the first-line treatment, as recommended by the 2020 KDIGO clinical practice guideline 1. This approach is crucial in reducing the risks of chronic kidney disease (CKD) and cardiovascular disease (CVD) in patients with type 2 diabetes. The treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and CKD should consider patient preferences, comorbidities, eGFR, and costs 1. Key points to consider in managing hyperglycemia and renal perfusion include:
- Hyperglycemia initially increases renal perfusion through hyperfiltration, but chronic hyperglycemia damages the glomerular filtration barrier, leading to diabetic nephropathy 1.
- The use of SGLT2 inhibitors has been shown to offer substantial benefits in reducing risks for CKD and CVD, and GLP-1 RAs are preferred additional agents due to their beneficial effects in reducing cardiovascular events 1.
- Regular monitoring of kidney function through eGFR and urine albumin-to-creatinine ratio measurements is essential in patients with diabetes and CKD 1.
- Early intervention is crucial in preventing permanent kidney damage, and the initial hyperfiltration phase represents a window of opportunity for prevention 1. In patients with type 2 diabetes and CKD, the goal should be to achieve individualized glycemic targets, and additional drugs should be selected based on patient preferences, comorbidities, eGFR, and costs 1. Overall, managing hyperglycemia with a focus on tight glycemic control and the use of SGLT2 inhibitors and GLP-1 RAs can help reduce the risks of CKD and CVD, and improve patient outcomes 1.
From the Research
Hyperglycemia and Renal Perfusion
- Hyperglycemia can have significant effects on renal perfusion and function, particularly in patients with diabetes mellitus 2, 3.
- Studies have shown that tight blood glucose control can reduce the risk of microvascular events, including progression of nephropathy 3.
- However, the optimal level of blood glucose control for renal perfusion and function is not well established, and more research is needed to determine the best approach 4, 5.
- Certain medications, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, have been shown to have renoprotective effects and may be beneficial for patients with hyperglycemia and renal disease 2, 5.
Effects of Hyperglycemia on Renal Function
- Hyperglycemia can lead to increased blood flow and glucose delivery to the kidneys, which can result in renal damage and dysfunction 6, 4.
- Prolonged hyperglycemia can also lead to the development of diabetic nephropathy, a leading cause of chronic kidney disease and end-stage renal disease 3.
- The use of certain medications, such as metformin, may need to be adjusted or avoided in patients with renal disease or impaired renal function 6, 2.
Management of Hyperglycemia and Renal Perfusion
- The management of hyperglycemia and renal perfusion requires a multifaceted approach, including lifestyle modifications, medication therapy, and close monitoring of blood glucose and renal function 6, 5.
- The choice of medication therapy should be individualized based on the patient's specific needs and medical history, and may involve the use of SGLT2 inhibitors, DPP-4 inhibitors, metformin, or insulin 2, 5.
- Further research is needed to determine the optimal approach to managing hyperglycemia and renal perfusion, and to develop personalized treatment strategies for patients with diabetes mellitus and renal disease 4, 3, 5.