Rationale and evidence
Rationale
Diabetes mellitus is associated with significant cardiovascular morbidity and mortality and is the leading cause of chronic kidney disease (CKD) worldwide. Type 2 diabetes is also increasing in prevalence. Evidence indicates that tight glycaemic control in diabetic patients results in clinically significant preservation of kidney function. As such, patients with stage 1–3 CKD stemming from type 1 or type 2 diabetes mellitus should aim to achieve a HbA1c target of approximately 6.5% to <8.0%.
Caution is recommended against intensively lowering HbA1c levels below this target range because of proven increased risks of hypoglycaemia and possibly death. While a lower HbA1c target (<6.5% or <7%) may be preferred in some patients, less stringent glycaemic goals (<7.5% or <8%) may be appropriate for others, especially those with a history of hypoglycaemia, long duration of diabetes, advanced atherosclerosis or advanced age/fragility.
SGLT2 inhibitors are first-line therapy for organ protection in patients with CKD (eGFR >= 30 ml/min/1.73m2 and diabetes) in addition to metformin therapy because of its glucose-lowering effects.
Evidence
de Boer IH, Caramori ML, Chan JCN, Heerspink HJL, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T, Tandon N, Tuttle KR, Wanner C, Wilkens KG, Zoungas S, Lytvyn L, Craig JC, Tunnicliffe DJ, Howell M, Tonelli M, Cheung M, Earley A, Rossing P. Executive summary of the 2020 KDIGO Diabetes Management in CKD Guideline: evidence-based advances in monitoring and treatment. Kidney Int. 2020 Oct;98(4):839-848.
KHA-CARI Guideline: Early chronic kidney disease: Detection, prevention and management. Johnson DW, Atai E, Chan M, Phoon RKS, Scott C, Toussaint ND, Turner GL, Usherwood T, Wiggins KJ. Nephrology 2013; 18(5): 340-50.
UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352 (9131): 854–65. 35. UKPDS. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).