Managing Chronic Kidney Disease in Patients With Diabetes

Sylvia Rosas, MD, MSCE; Mark Harmel, MPH, CDCES


June 09, 2022

This transcript has been edited for clarity.

The American Diabetes Association has recently released the 2022 Standards of Medical Care in Diabetes. Among the highlights are the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors to slow the progression of kidney and cardiovascular disease, the use of nonsteroidal mineralocorticoid receptor agonists, such as finerenone, to slow progression of kidney disease, and the use of the new race-free equation that is currently being implemented by the National Kidney Foundation and the American Society of Nephrology.

The SGLT2 inhibitors have been shown to slow progression of kidney disease, decrease albuminuria, and have a cardiovascular benefit in patients with and without diabetes.

Chronic kidney disease affects 37 million Americans and 850 million people around the world. Diabetes is the most common cause of kidney disease in the United States. Unfortunately, chronic kidney disease is an asymptomatic disease, so symptoms only appear very late in the disease when people are already needing dialysis or transplantation.

Therefore, screening for chronic kidney disease in high-risk populations, such as those who have diabetes, hypertension, or a family history of kidney disease, is of vital importance. Unfortunately, not everybody who is at high risk is being screened; therefore, it's very important that when you discuss it with your provider, if you're at high risk, you at least have this test annually.

There are two tests. One is a blood test to measure creatinine, which we use to estimate glomerular filtration rate, or GFR for short. The second is to measure albumin in the urine, or albuminuria, to see how much protein is coming down in the urine, which tells us how much damage the kidney has.

Often, I get asked when is a good time to refer to a kidney specialist? Although I think everybody should see a kidney doctor, it's impossible for 15,000 people to see 37 million Americans; therefore, comanagement with primary care providers is vital.

Refer patients when the diagnosis is uncertain or it's not behaving like diabetic kidney disease. For example: The disease is rapidly progressing, there's blood in the urine, or there are systemic symptoms that point toward a different disease and that patient may need a kidney biopsy.

In addition, there are patients who may need referral because they need dialysis or transplantation. Those patients have kidney function that is relatively low, where their GFR < 30. Those patients need to be seen by a specialist.

Again, you should always refer when there are any questions that a kidney specialist could help with, such as management of blood pressure, electrolyte imbalances, high potassium, low calcium, or high phosphorus. Those are all complications of kidney disease that a kidney specialist is able to handle with ease.

If you have additional questions, there is a new resource in the 2022 Standards of Medical Care in Diabetes. Chapter 11 is completely dedicated to the management of chronic kidney disease and may be very helpful in answering some of your questions.

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