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High A We are confident that the true effect is close to the effect estimate. B Moderate The true effect is likely to be close to the effect estimate, but there is a.
USE OF THE CLINICAL PRACTICE GUIDELINE
DISCLOSURE
Comprehensive care in patients with diabetes and CKD
Practice point 1.1.1: Patients with diabetes and chronic kidney disease (CKD) should be managed with a comprehensive strategy to reduce the risk of kidney disease progression and cardiovascular disease (Figure 2). The presence of albuminuria is associated with an increased risk of progression of CKD and development of renal failure in patients with CKD and diabetes. Practice point 1.2.1: For patients with diabetes, albuminuria and normal blood pressure, treatment with ACEi or ARB can be considered.
The benefits of RAS blockade have been less studied in patients with diabetes and CKD without hypertension. Practice point 1.3.1: Physicians should counsel patients with diabetes and CKD to reduce exposure to secondhand smoke.
Glycemic monitoring and targets in patients with diabetes and CKD
The working group also considered that the limitations of HbA1c, including underestimation or overestimation of the actual degree of glycemic control compared with directly measured blood glucose levels, would be important for patients. In the working group's assessment, most, but not all, patients with diabetes and CKD would choose long-term glycemic monitoring with HbA1c despite these limitations. Considerations for implementation. Patients with T1D or T2D and CKD are likely to benefit from glycemic monitoring with HbA1c.
This recommendation applies to adults and children of all race/ethnicity groups, both sexes, and to patients with kidney failure treated by dialysis or kidney transplantation. Practice point 2.1.1: Monitoring long-term glycemic control by HbA1c twice a year is reasonable for patients with diabetes. In both T1D or T2D, lower achieved levels of HbA1c <7% (<53 mmol/mol) versus mmol/mol) reduce the risk of overall microvascular complications, including nephropathy and retinopathy, and macrovascular complications in some RCTs.99–103 The potential harm of monitoring by HbA1c is that it may underestimate (more commonly) or overestimate (less commonly) the actual degree of glycemic control compared to directly measured blood glucose in advanced CKD.
Measuring HbA1c more frequently would be reasonable in patients with adjustments in glucose-lowering medication, changes in lifestyle factors, or marked changes in measured blood glucose values; or those who are less concerned about the burden or costs of more frequent laboratory tests.124 Practice point 2.1.2: Accuracy and precision of HbA1c measurement declines with advanced CKD (G4-G5), particularly among patients with treated with dialysis, in which HbA1c measurements have low reliability. Correlations of directly measured blood glucose levels with 3 glycemic biomarkers—HbA1c, glycated albumin, and fructosamine—were increasingly worse with advanced stages of CKD (G4-G5), especially renal failure treated with dialysis. Practice point 2.1.3: A glucose management index (GMI) derived from continuous glucose monitoring (CGM) data can be used to index glycemia for individuals in whom HbA1c is inconsistent with glucose levels in directly measured blood or clinical symptoms.
CGM and self-monitoring of blood glucose (SMBG) provide direct measurements of interstitial and blood glucose, respectively, that are not known to be biased by CKD or its treatments, including dialysis or kidney transplantation (Figure 7126) . GMI is a measure of average blood glucose calculated by CGM and expressed in units of HbA1c (%), facilitating the interpretation of HbA1c values. For example, if HbA1c is lower than a concurrent measure of BMI, HbA1c may be interpreted as underestimating mean blood glucose from the change in measurement, allowing HbA1c targets to be adjusted accordingly. 127,128 GMI may be useful for patients with advanced CKD, including those treated with dialysis, for whom HbA1c reliability is low.
CKDBias high
Therefore, if there is a clinical concern that HbA1c may provide biased estimates of long-term glycemia (eg, discrepancies with SMBG, random blood glucose levels, or hypoglycemic or hyperglycemic symptoms), it is reasonable to use CGM to generate a glucose management indicator (GMI ).125a The GMI can be derived from CGM performed with results either blinded to the patients under monitoring (“professional” version) or available to the patient in real time. It should be noted that assay bias of HbA1c relative to GMI can potentially change over time in a patient, particularly when there are clinical changes affecting red blood cell turnover or protein glycation. Practice point 2.1.4: Daily glycemic monitoring with CGM or self-monitoring of blood glucose (SMBG) can help prevent hypoglycaemia and improve glycemic control when antihyperglycaemic therapies associated with risk of hypoglycaemia are used.
In addition to long-term glycemic control, minute-to-minute glycemic variability and episodes of hypoglycemia are important therapeutic targets for people with diabetes and.
Bias low Anemia
Lifestyle interventions in patients with diabetes and CKD
The number of RCTs analyzing the effects of diet in people with diabetes and CKD is small. People with diabetes and CKD, compared to the general population, are often required to follow more complex nutrient intake recommendations. According to the Working Group's assessment, this recommendation is reasonable for those with diabetes and CKD.
Very few RCTs have looked at dietary modification in people with diabetes and chronic kidney disease. Practice Point 3.1.4: Licensed nutrition providers, registered dietitians and diabetes educators, community health workers, peer counselors, or other health professionals should be involved in the multidisciplinary nutrition care of patients with diabetes and chronic kidney disease. Compare the benefits and harms of plant versus animal proteins in people with diabetes and chronic kidney disease.
The recommendation places less weight on the lack of direct evidence for benefits in people with diabetes and specifically chronic kidney disease. Balance between advantages and disadvantages. The various health benefits of regular physical activity are well known.1206 Patients with diabetes and chronic kidney disease have lower levels of physical activity, along with reduced overall fitness levels compared to the general population.207 In fact, more than two-thirds of adults with chronic kidney disease in the US do not meet the physical activity levels recommended by the AHA and the. Similar benefits are expected in people with diabetes and chronic kidney disease who exercise regularly.
Quality of evidence. Evidence supporting physical activity in people with CKD derives from epidemiologic and/or small single-center prospective studies. Patients with diabetes and CVD who are at higher risk of adverse events (such as falls during vigorous physical activity) and those with pre-existing CVD should consult with their health care providers before engaging in exercise. with high intensity. Further studies should be conducted to compare the benefits and risks of different intensities (light, moderate and vigorous) and types of physical activity levels in those with diabetes and CKD.
Antihyperglycemic therapies in patients with type 2 diabetes (T2D) and CKD
For patients with T2D, chronic kidney disease, and an eGFR of $30 mL/min per 1.73 m achieving glycemic goals with metformin as the sole antihyperglycemic agent, data supporting the use of an SGLT2i are limited. Some patients with T2D and an eGFR of $30 ml/min per 1.73 m2 will not achieve glycemic goals with lifestyle therapy. In addition, initiation of these drugs is not recommended in patients with an eGFR <30 ml/min per 1.73 m2.
Evaluate the safety, efficacy, and potential cardiovascular and renal protective benefits of metformin use in patients with T2D and chronic kidney disease, including those with an eGFR<30 ml/. Implementation considerations. Patients with T2D, CKD and an eGFR$30 ml/min per 1.73 m2 benefited from SGLT2i therapy in RCTs. For patients with chronic kidney disease with an eGFR$30 ml/min per 1.73 m2, the current KDIGO guideline recommends the use of an SGLT2i along with metformin.
The current KDIGO guideline recommends the use of both metformin and an SGLT2i for most patients with T2D, CKD and an eGFR$30 ml/min per 1.73 m2. Studies have focused on long-term (> 5 years) safety and efficacy of SGLT2i treatment among patients with T2D and CKD. For patients with T2D, CKD and an eGFR $30 ml/min per 1.73 m2, SGLT2i agents are preferred over GLP-1 RA as initial anti-hyperglycemic and organ-protective agents with metformin.
These data indicate that there is moderate quality evidence that GLP-1 RA reduces MACE in patients with type 2 diabetes. Future studies should focus on the long-term safety and efficacy (>5 years) of GLP-1 RA use in patients with T2D and chronic kidney disease. Future studies should confirm the safety and clinical benefit of GLP-1 RA for patients with type 2 diabetes and renal transplantation.
Approaches to management of patients with diabetes and CKD
Bolignano et al. Aldosterone antagonists for prevention of progression of chronic kidney disease. Cochrane Database Syst Rev. Nataleet al. Potassium binders for chronic hyperkalemia in people with chronic kidney disease. Cochrane Database Syst Rev. Ruospo et al. its progression.Cochrane Database Syst Rev.
Loet al.Insulin and glucose-lowering agents for the treatment of people with diabetes and chronic kidney disease.Cochrane Database Syst Rev.2018;9:CD011798.292. Ikizler TA, Burrowes JD, Byham-Gray LD, et al., KDOQI Nutrition in CKD Guideline Work Group.
