In 2007, the National Kidney Foundation published guidelines to assist clinicians in managing patients with diabetes and CKD.10 The primary health outcome addressed by the KDOQI guideline update is all-cause mortality. Secondary health outcomes include ESRD, CV death and nonfatal CV events, vision loss, amputation, and severe hypoglycemic events.11 Since the original publication, a significant body of high-quality evidence has emerged, resulting in updates to three of the nine practice guidelines (Table 2).11 Guideline statements are graded by strength of recommendation (Table 3) and quality of the supporting evidence (Table 4).11
As a result, for patients at lower risk of hypoglycemia (stages 1 to 3 CKD), the recommendation for a target A1C level of 7% to prevent or delay progression of microvascular complications of diabetes, including kidney disease, is upgraded to Level 1A.11 Hypoglycemia risk increases with decreased renal function, particularly at stages 4 and 5 CKD, and in patients with diabetes treated to an A1C of less than 7%.6,15,16
For patients at higher risk of hypoglycemia, the three studies demonstrate similar endpoint outcome reductions in CV events, CV death, and ESRD among conventional versus intensive treatment groups.12–14 Therefore, the KDOQI recommends that patients at risk of hypoglycemia not be treated to a target A1C of less than 7% (Level 1B), and suggests an A1C greater than 7% in patients with stages 4 and 5 CKD who have limited life expectancy or significant comorbidities (Level 2C).11 CKD has a significant effect on drug selection and monitoring of pharmacotherapeutic effects in patients with diabetes.17 As the patient's renal function declines, some oral agents (except thiazolidinediones) require dose adjustment, and many are not recommended at stages 3 through 5 CKD. Insulin remains the core of therapy for control of glucose in patients with diabetes and advanced CKD, and in particular, for those on dialysis.17 See the KDOQI guideline update for a complete list of drug dosing recommendations.11
The recently published Kidney Disease-Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease addresses managing lipid status in patients with CKD.22 KDIGO recommendations specific to patients with diabetes and CKD focus on adults ages 18 to 49 years with CKD who are not treated with chronic dialysis or kidney transplantation. In this population, statin therapy is recommended for patients with one or more of the following chronic conditions:
Consistent with the KDOQI guideline, initiation of statins or a statin/ezetimibe combination is not recommended in patients already on dialysis or who have had transplantation; lower-dose statin therapy is recommended for patients with stages 3 through 5 CKD.22
As the authors of the KDOQI guidelines note, unanswered questions remain. Recommendations for future research related to each of the updated guidelines include:
Because the updated clinical practice guideline for managing BP in patients with CKD was published after the KDOQI diabetes guideline update, the KDOQI guideline does not incorporate the new BP guidelines.28 Future KDOQI updates will likely incorporate the KDIGO recommendations.
The KDOQI update provides a review of the current evidence for best practices in the management of diabetes and CKD. Primary care clinicians, including PAs, play a crucial role in preventing or delaying the progression of CKD in patients with diabetes. Beginning this year, certified PAs will transition to a new certification maintenance process involving performance improvement continuing medical education. In this process, PAs complete a quality improvement project related to their clinical practice at least twice in every 10-year certification maintenance cycle.29 PAs caring for patients with diabetes can use the KDOQI diabetes and CKD guideline, along with the 2012 update, to develop clinical policies and performance measures to fulfill this requirement.
Under the updated guidelines, key benchmarks for glycemic control and management of dyslipidemia and albuminuria are:
These benchmarks also can be used by PAs who care for patients with CKD to develop performance improvement CME plans.
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