Physicians debate best management strategy for patient with type 2 diabetes and CKD

Physicians debate best management strategy for patient with type 2 diabetes and CKD

‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center

Abstract: https://www.acpjournals.org/doi/10.7326/M24-0764 

URL goes live when the embargo lifts

In a new Annals ‘Beyond the Guidelines’ feature, an endocrinologist and a nephrologist discuss controversies regarding the care of patients with type 2 diabetes (T2D) and chronic kidney disease (CKD) and how they would apply the consensus statement to the care of an individual patient with T2D who is unaware that he has CKD. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine. 

Concomitant with rising rates of obesity, the prevalence of T2D in the United States continues to increase, especially in certain ethnic and racial groups. While approximately one third of persons with T2D will develop CKD over their lifetime, nearly half of such persons are not receiving guideline-based screening for CKD. In 2022, the ADA and KDIGO published a consensus statement based on high-quality RCTs that recommended annual CKD screening for patients with T2D beginning at the time of diagnosis, discussed the role of therapeutic lifestyle changes to slow progression of CKD and minimize morbidity, and proposed a framework for the rational use of novel pharmacotherapeutic agents for patients with T2D and CKD to improve renal and cardiovascular outcomes.

BIDMC Grand Rounds discussants, Giulio R. Romeo, MD, Assistant Professor of Medicine at Harvard Medical School, a member of the Division of Endocrinology, Diabetes & Metabolism at Beth Israel Deaconess Medical Center, and Associate Medical Director, Adult Diabetes Section, at Joslin Diabetes Center, Boston, Mass., and Sylvia E. Rosas, MD, MSCE Associate Professor of Medicine at Harvard Medical School, a member of the Division of Nephrology at Beth Israel Deaconess Medical Center, and Director of the Latino Kidney Clinic at Joslin Diabetes Center, Boston, Mass., recently debated the case of a 68-year old man with both T2D and CKD. 

In their assessment, both Drs. Romeo and Rosas both expressed concern about the lack of guideline-based screening for CKD among persons with T2D in real-world settings. Dr. Romeo discusses clinical trials that demonstrate that early detection and treatment of T2D can reduce diabetes-related complications including renal morbidity. Dr. Rosas points out that many patients with T2D and CKD who are at risk for future kidney failure are unaware of their CKD diagnosis. Dr. Romeo presented data that treatment with SGLT2i reduces the rate of CKD progression and that the benefit is not mediated primarily by improved glycemic control. He notes that treatment with GLP-1RA reduces albumin to creatinine ratio (ACR) but to date has not been shown to slow eGFR decline. Dr. Romeo notes that combination therapy with SGLTi and GLP-1RA reduces cardiovascular morbidity to a greater extent than either alone. Dr. Rosas presented data from seminal trials of SGLTi therapies in patients with CKD and concluded that at least 3 available SGLTi reduce composite outcomes that include reduction of eGFR by at least 50%, onset of ESRD, and death due to cardiovascular or renal causes. In addition, Dr. Rosas notes that finerenone, an ns-MRA, reduced CKD progression and a composite cardiovascular outcome in patients with T2D and CKD. Both Drs. Romeo and Rosas emphasized the importance of multidisciplinary care for selected patients with T2D and CKD.

A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.

Media contacts: For an embargoed PDF, please contact Angela Collom at [email protected]. For an interview with the discussants, please contact Kendra McKinnon at [email protected].

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