New CKD in a Patient With Diabetes: What to Do?

Case Presentation

A 58-year-old White woman presents as a new patient. She has type 2 diabetes, hypertension, and dyslipidemia, all diagnosed 7 years ago. She moved to the area 2 years ago but has not made a face-to-face appointment until today. She believes that her conditions are well-managed, and she denies any current symptoms. She usually gets her labs done annually on her birthday. She has a self-monitoring glucose meter that she occasionally checks if she feels "funny." She does not take her meter with her when she leaves the house.

She has been compliant with her medications:

Metformin 1000 mg twice daily;
Glipizide 5 mg twice daily;
Atorvastatin 40 mg daily; and
Hydrochlorothiazide 25 mg daily.

Allergies: She developed a cough when taking angiotensin-converting enzyme inhibitors.

Social history: She is a real estate agent ("always on the go"). She engages in no additional physical activity but tries to eat healthy even though she eats out a lot. She does not use tobacco or alcohol. She was divorced 9 months ago; until that time, she lived with her husband and adult child.

Exam: The patient's blood pressure is 148/88 mm Hg (when rechecked, 144/84 mm Hg); pulse, 82 beats/min; respiratory rate, 12 breaths/min; body mass index, 32 kg/m².

Other than obesity, her physical exam is globally normal.

Her lab results, comparing the previous and current year, are shown in the Table.

Table. Lab Results in Today's Patient

Laboratory Parameter	October 2019	October 2020
Sodium (mEq/L)	140	138
Potassium (mEq/L)	4.0	4.0
Chloride (mmol/L)	100	98
Calcium (mg/dL)	8.8	8.8
Carbon dioxide (mmol/L)	26	26
Glucose (mg/dL)	148	162
BUN (mg/dL)	14	14
Creatinine (mg/dL)	1.0	1.1
eGFR (non-AA) (mL/min)	60	55
A1c	7.6%	8.4%
Urine albumin-creatinine ratio (mg/g)	62	98
Total cholesterol (mg/dL)	160	164
LDL-C (mg/dL)	88	86
HDL-C (mg/dL)	42	38
Triglycerides (mg/dL)	148	196
BUN = blood urea nitrogen; eGFR = estimated glomerular filtration rate; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; non-AA = non–African American

Discussion

Problem list:

Type 2 diabetes, uncontrolled
Hypertension, not at goal
Chronic kidney disease (CKD), stage 3A A2
Dyslipidemia controlled on high-intensity statin
Obesity

This is a relatively common case presentation in primary care, especially during the COVID-19 pandemic. Many people have not continued their routine preventive care or monitoring. Fear of contracting COVID has been a major contributor to a reduction in normal disease maintenance visits. To complicate this further, diabetes, hypertension, dyslipidemia, and kidney disease are silent conditions that need active monitoring for successful management. A symptom-based approach is too little too late.

Kidney Disease: Improving Global Outcomes (KDIGO) has published updated CKD guidelines for the person with diabetes. This discussion will highlight the applications of the guideline recommendations as they apply to this case.

How Do We Approach This Patient?

We want to establish a collaborative relationship, thanking the patient for her honesty and for getting her labs completed and asking about her goals for the visit. We will need to decide how to establish treatment priorities that are important to her.

She is aware of her diabetes, hypertension, and dyslipidemia, but she is not aware of the CKD. She has a declining glomerular filtration rate (GFR) and albuminuria. The albuminuria is important because it is an independent risk factor for cardiovascular disease. Less than 50% of people at high risk for kidney failure are aware of this risk.

What is the recommended course of action for lifestyle and nutrition behaviors? The KDIGO 2020 guideline recommends the following lifestyle and nutrition behaviors:

Patients with diabetes and CKD should consume a balanced diet that is high in fresh fruits and vegetables, whole grains, fiber, legumes, plant-based proteins, nuts, and unsaturated fats. Processed meats, simple carbohydrates, added sugars, and sweetened beverages should be minimized.
There is no specific limitation to protein intake in people with CKD (maintain 0.8 g/kg/d).
Engage in moderate-intensity physical activity at least 150 min/wk.
Avoid any form of tobacco products.
Limit sodium intake to 2 g/d. Our patient eats out a lot, which often involves higher-sodium meals.

What is the recommended approach to diabetes? The KDIGO 2020 guideline recommends the following for hyperglycemia management:

People with diabetes and CKD should have an individualized A1c goal between 6.5% and 8.0%.
Consistent with the American Diabetes Association guidelines, all people with an eGFR > 30 mL/min should be on metformin and a sodium-glucose cotransporter 2 (SGLT2) inhibitor. Both medications can be used in stage 1-3 CKD.
Metformin should be used at the maximum effective and tolerated dose in people with stage 1, 2 and 3A CKD unless the patient has specific contraindications.
There is strong evidence that SGLT2 inhibitors reduce the progression of diabetic nephropathy and should be implemented in all people with stage 1-3 CKD.
Eat a well-rounded healthy diet and engage in regular physical activity as described above.

What is the recommended approach to hypertension? The KDIGO 2020 guideline recommends the following for hypertension management:

All people with diabetes and CKD should be on a renin-angiotensin system (RAS) blocker. This is especially important for people who have albuminuria. People with diabetes, reduced GFR, and normal albumin excretion are at lower risk for CKD progression. Our patient tried an angiotensin-converting enzyme inhibitor and developed a cough, but we do not see any record of the patient taking an angiotensin II receptor blocker (ARB).
All RAS inhibitors should be titrated to the maximum tolerated dose to maximize nephropathy benefit.
Restrict dietary sodium to 2 g/d as noted.
Eat a well-rounded healthy diet and engage in regular physical activity as described above.

What is recommended for CKD? The KDIGO 2020 guideline recommends the following to prevent CKD progression:

The approach to the patient with diabetes and CKD should be based on the following principles:
- Comprehensive care that includes strategies to reduce kidney disease progression and cardiovascular disease;
- Team-based care that will include primary care, nephrology, cardiology, endocrinology/diabetology, diabetes nurse educators, pharmacists, dietitians, and other clinicians; and
- All of the recommended approaches above.
Timely referral to nephrology to assist in management.
Comprehensive self-management education to help with ongoing disease management.

Case Continued

At this visit, we reviewed with the patient that her average glucose level has increased and she has CKD. Although this may be concerning, we can do a lot to reduce her risk for complications. Specifically, we want to help her optimize her glucose and blood pressure and build a team to support her.

Optimize glucose level. We discuss treatment goals and agree to aim for an A1c < 7.5%. We will consider adding an SGLT2 inhibitor to mildly lower her glucose (at this GFR), lower her blood pressure, and help reduce her risk for cardiovascular and kidney disease. We may need to modify the sulfonylurea (glipizide) dose to prevent her from becoming hypoglycemic.

We have given her advice regarding symptoms of hypoglycemia and how to manage such symptoms. With an elevated A1c, we can add the SGLT2 first and then monitor her. We will ask her to check her glucose more frequently during this time of change, to assess efficacy and potentially prevent hypoglycemia during the transition.

Our patient has had a tough personal year with the pandemic and a divorce. Her routines have surely changed. We will refer her to a self-management educational program that includes lifestyle advice and a dietitian to help her establish a nutrition plan that is both healthy and will work within her current life circumstances. We ask her to consider taking walks after meals as a way to increase activity and lower postmeal glucose. She can start with walking for 10 minutes after each meal and work up to longer walks as she becomes more comfortable. The goal is to walk for 150 min/wk, or about 30 minutes 5 days per week.

Optimize her blood pressure. We discuss treatment goals and agree on a blood pressure of 130/80 mm Hg or lower if tolerated. We recommend an ARB at the maximum tolerated dose. This can help reduce the progression of nephropathy and is not associated with a cough. Because we have discussed starting an SGLT2 inhibitor, we may have to delay starting the ARB, introducing only one drug at a time to see how her kidneys handle each medication. We may be able to stop the diuretic if her blood pressure responds to the ARB. As part of the nutrition consultation, we recommend that she discuss ways to reduce the sodium in her diet to no more than 2 g/d.

We will work with her to reduce her risks and bring a team together to help her. In addition to herself, this team will include her primary care practitioner, a diabetologist, a nephrologist, a dietitian (who may be part of the team that delivers the self-management program), an eye specialist, and anyone else she thinks can help her.

It will take time to get this all done, so we will start with just one or two things to work on between each visit. We schedule an appointment with her in 1 month to see how she is doing and to touch base about her experience with walking after meals and meeting with the dietitian.

Further Resources for Patients and Clinicians

From the KDIGO Clinical Practice Guideline for Diabetes Management in CKD:
Top 10 Takeaways for Patients
Top 10 Takeaways for Clinicians
Diabetes Management in Chronic Kidney Disease: Synopsis of the 2020 KDIGO Clinical Practice Guideline

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