The American Diabetes Association, in collaboration with KDIGO, has published a simplified algorithm for the treatment of patients with diabetes and chronic kidney disease. The first step here is lifestyle adjustment. In particular, obesity should be avoided - ideally through a healthy diet, more exercise and avoiding too much table salt. But smoking and an increased protein intake are also risk factors for diabetic nephropathy.
However, lifestyle changes alone are not sufficient in most cases, so the drug treatment is indicated. Besides metformin, other classes of drugs are available: SGLT2 inhibitors, for example, have a kidney-protective effect. The same applies to the GLP-1 receptor agonists liraglutide, semaglutide and dulaglutide.
The goal of therapy is to prevent or slow down diabetic nephropathy and the resulting complications. Secondary damage caused by diabetes or chronic kidney disease should also be avoided.
Therapy goals are defined to control the success of the treatment. According to expert recommendations, these are:
Caution is advised when setting goals. One size does not fit all. Rather, the therapy should be individually adapted, whereby it is important, for example, to avoid hypoglycaemia. Patient safety should also be taken into account when setting blood pressure.
But it is not only in therapy planning that physicians should be careful. The interpretation of test results can also be deceptive. For example, in chronic kidney disease stage 3b or higher, the HbA1c can be falsely low. This makes individual counselling and treatment of each affected person all the more important.
Metformin is still considered the gold standard in first-line therapy for people with diabetes with kidney disease.
However, SGLT2 inhibitors also have an important role to play. Studies have shown that despite an initial drop in eGFR after about 18 months, the drugs halve the natural further drop in glomerular filtration rate. And this renal protective effect persists with further administration. Thus, a possible need for dialysis can be delayed, which has positive effects on the quality of life of the patients.
Some RLP-1 receptor agonists have a similar nephroprotective effect. In a recent study, tirzepatide showed the desired reduction in eGFR decline after 24 weeks of use.
The newest addition to the group of therapeutics that can be used here are non-steroidal mineralocorticoid receptor antagonists (MRAs). In studies, these drugs were able to significantly reduce the cardiovascular risk as well as the progression of kidney damage.
The guidelines for the treatment of CKD in type 2 diabetics are primarily based on lifestyle adjustment and adequate drug treatment. This should always be individually adapted - taking into account possible risk factors and comorbidities. Several new drug classes are by now available as options.
Session by Merker, Ludwig, Dr., Diabetologie im MVZ am Park Ville D’Eu Haan. English session title: Liver, kidney, heart in diabetes mellitus type 2 - Guideline-based therapy - Diabetes mellitus type 2 and kidney. Original Session German Title: Leber, Niere, Herz bei Diabetes Mellitus Typ 2 – Leitliniengerechte Therapie – Diabetes Mellitus Typ 2 und Niere. The German Diabetes Society's (DDG) Congress 2023, Berlin, 17 May 2023