Management of chronic kidney disease in type 2 diabetes: screening, diagnosis and treatment goals, and recommendations

Effect of tirzepatide on albuminuria levels and renal function in patients with type 2 diabetes mellitus: A systematic review and multilevel meta-analysis

AIM

The present systematic review aimed to summarize the available evidence from published randomized controlled trials (RCTs) regarding the effect of tirzepatide on albuminuria levels and renal function in patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

Medline (via PubMed), Cochrane Library and Scopus were searched until 20 October 2023. Double-independent study selection, data extraction and quality assessment were performed. Evidence was pooled with a three-level mixed-effects meta-analysis.

RESULTS

In total, 9533 participants from eight RCTs were analysed. All RCTs had a low risk of bias, according to the Cochrane Collaboration tool (RoB2). Tirzepatide was associated with a significantly greater reduction in urine albumin-to-creatinine ratio compared with controls [mean difference (MD) -26.9%; 95% confidence interval (CI) (-34.76, -19.04); p < .001; level of evidence (LoE) moderate]. This effect remained significant in participants with baseline urine albumin-to-creatinine ratio ≥30 mg/g [MD -41.42%; 95% CI (-54.38, -28.45); p < .001; LoE moderate]. Based on subgroup analysis, the comparative effect of tirzepatide was significant against placebo and the insulin regimen, whereas no difference was observed compared with semaglutide. The beneficial effect of tirzepatide on albuminuria levels remained significant across all investigated doses (5, 10 and 15 mg), showing a dose-response relationship. A neutral effect was observed on the estimated glomerular filtration rate [MD 0.39 ml/min/1.73m2 ; 95% CI (-0.64, 1.42); p = .46; LoE moderate].

CONCLUSION

Our findings suggest that tirzepatide probably leads to a significant reduction in albuminuria across all administered doses, while its use is associated with a neutral effect on creatinine clearance as a measure of renal function.

Peter WL, Shubrook JH. Type 2 Diabetes and Chronic Kidney Disease: An Opportunity for Pharmacists to Improve Outcomes

Chronic kidney disease (CKD) is an important contributor to end-stage kidney disease, cardiovascular disease, and death in people with type 2 diabetes (T2D), but current evidence suggests that diagnosis and treatment are often not optimized. This review examines gaps in care for patients with CKD and how pharmacist interventions can mitigate these gaps. We conducted a PubMed search for published articles reporting on real-world CKD management practice and compared the findings with current recommendations. We find that adherence to guidelines on screening for CKD in patients with T2D is poor with particularly low rates of testing for albuminuria. When CKD is diagnosed, the prescription of recommended heart-kidney protective therapies is underutilized, possibly due to issues around treatment complexity and safety concerns. Cost and access are barriers to the prescription of newer therapies and treatment is dependent on racial, ethnic, and socioeconomic factors. Rates of nephrologist referrals for difficult cases are low in part due to limitations of information and communication between specialties. We believe that pharmacists can play a vital role in improving outcomes for patients with CKD and T2D and support the cost-effective use of healthcare resources through the provision of comprehensive medication management as part of a multidisciplinary team. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across healthcare systems to ensure that comprehensive medication management can be optimally implemented.

Neutrophil-to-Lymphocyte Ratio as a Potential Biomarker to Managing Type 2 Diabetes Mellitus and Predicting Disease Progression

Introduction Diabetes is a chronic disease that causes dysregulation of blood glucose. Type 2 diabetes mellitus (T2DM) could result in long-term inflammatory conditions that affect different organs of the body. Despite the availability of diagnostic markers like glycated hemoglobin (HbA1c) for T2DM, it is essential to find an appropriate marker that could predict long-term complications. This study evaluates the potential role of neutrophil-to-lymphocyte ratio (NLR) in predicting disease progression and treatment responses.  Methods This case-control study was carried out among 160 T2DM patients and 132 non-diabetic persons. Blood samples were collected from each participant and were processed for hemoglobin, HbA1c, iron, ferritin, and complete blood picture (NLR).  Results The study showed that there was a significant variation in the serum levels of ferritin (264.8±611.6 ng/ml versus 168.3±364.7 ng/ml, p=0.392), iron (4.095±8.851 mcg/dl versus 55.20±37.62 mcg/dl, p=0.0111), and HbA1c (8.169±1.635% versus 5.668±0.5260% p<0.0001) among T2DM patients compared to non-diabetic persons. The NLR values (4.189±4.154 versus 4.095±8.851, p=0.009) among patients with T2DM significantly varied with that of non-diabetic persons. A significant negative correlation was noticed between the serum levels of iron and NLR (r=-0.17, p=0.014) and a positive correlation was noticed between HbA1c and NLR (r=0.19, p=0.014). The serum levels of iron revealed a significant positive correlation with the serum levels of ferritin (r=0.24, p=0.002) and hemoglobin percentage (r=0.41, p=0.008). HbA1c revealed a significant positive correlation with NLR (r=0.19, p=0.014). Additionally, a significant negative correlation was observed between iron with NLR (r=-0.17, p=0.029) and hemoglobin percentage with NLR (r=-0.30, p=0.005). However, no such correlation was demonstrated among non-diabetic persons. With an accuracy of 89.85% and high sensitivity and specificity, NLR showed diagnostic accuracy like HbA1c.  Conclusions NLR demonstrated equivalent efficacy to HbA1c in predicting glycemic control. Since diabetes affects different organs of the body, evaluating NLR probably predicts inflammation. Therefore, NLR could be useful in the management of T2DM and in predicting long-term complications.

Pharmacotherapy considerations with finerenone in the treatment of chronic kidney disease associated with type 2 diabetes

PURPOSE

This review provides an overview of the management of chronic kidney disease (CKD) associated with type 2 diabetes (T2D), how the novel treatment class of nonsteroidal mineralocorticoid receptor antagonists (MRAs) fits within the treatment landscape, and how pharmacists can contribute to the multidisciplinary care of patients with CKD associated with T2D.

SUMMARY

Optimizing pharmacotherapy for patients with CKD associated with T2D is critical to prevent or slow progression to end-stage kidney disease and reduce the incidence of cardiovascular events. However, many patients with CKD receive suboptimal treatment, in part because of the high complexity of care required, a lack of disease recognition among providers and patients, and a failure to utilize new kidney-protective therapies. Finerenone is the first nonsteroidal, selective MRA to be approved by the US Food and Drug Administration and the European Medicines Agency for the treatment of adult patients with CKD associated with T2D. Clinical trials have demonstrated that finerenone significantly reduces the risk of cardiorenal disease progression vs placebo and has a reduced risk of hyperkalemia compared to traditional steroidal MRAs. Initiation of finerenone should follow evaluation of baseline estimated glomerular filtration rate and serum potassium levels. Consideration of potential drug-drug interactions, follow-up monitoring of potassium levels, and coordination of changes in pharmacotherapy across the patient care team are also important.

CONCLUSION

Finerenone is a valuable addition to the treatment landscape for CKD associated with T2D. Through their expertise in -medication -management, transitions of care, and patient education, clinical pharmacists are well positioned to ensure patients receive safe and effective -treatment.

Early diagnosis of chronic kidney disease in patients with diabetes in France: multidisciplinary expert opinion, prevention value and practical recommendations

Diabetes is the leading cause of end-stage kidney disease (ESKD), accounting for approximately 50% of patients starting dialysis. However, the management of these patients at the stage of chronic kidney disease (CKD) remains poor, with fragmented care pathways among healthcare professionals (HCPs). Diagnosis of CKD and most of its complications is based on laboratory evidence. This article provides an overview of critical laboratory evidence of CKD and their limitations, such as estimated glomerular filtration rate (eGFR), urine albumin-to-creatinine ratio (UACR), Kidney Failure Risk Equation (KFRE), and serum potassium. eGFR is estimated using the CKD-EPI 2009 formula, more relevant in Europe, from the calibrated dosage of plasma creatinine. The estimation formula and the diagnostic thresholds have been the subject of recent controversies. Recent guidelines emphasized the combined equation using both creatinine and cystatin for improved estimation of GFR. UACR on a spot urine sample is a simple method that replaces the collection of 24-hour urine. Albuminuria is the preferred test because of increased sensitivity but proteinuria may be appropriate in some settings as an alternative or in addition to albuminuria testing. KFRE is a new tool to estimate the risk of progression to ESKD. This score is now well validated and may improve the nephrology referral strategy. Plasma or serum potassium is an important parameter to monitor in patients with CKD, especially those on renin-angiotensin-aldosterone system (RAAS) inhibitors or diuretics. Pre-analytical conditions are essential to exclude factitious hyperkalemia. The current concept is to correct hyperkalemia using pharmacological approaches, resins or diuretics to be able to maintain RAAS blockers at the recommended dose and discontinue them at last resort. This paper also suggests expert recommendations to optimize the healthcare pathway and the roles and interactions of the HCPs involved in managing CKD in patients with diabetes.

Cardiovascular Outcomes in Patients With Diabetes and Kidney Disease: JACC Review Topic of the Week

Chronic kidney disease (CKD) and cardiovascular disease (CVD) have a significant inter-relationship in patients with diabetes. Controlling blood pressure, dyslipidemia, and glucose levels is a common treatment approach to managing CVD risk in patients with CKD and diabetes; despite strict control, however, a high residual risk remains. This review focuses on patients who require pharmacotherapy, in whom new and existing cardiorenal therapies (renin-angiotensin-aldosterone system inhibitors, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists) with differing mechanisms of action and safety profiles can reduce cardiovascular risk beyond the outcomes achieved with blood pressure, dyslipidemia, or glycemic control alone. Several treatment guidelines have been updated recently to reflect new evidence. Studies of these cardiorenal agents used in combination are ongoing, and results are awaited with interest, with the hope that potential synergistic effects may lead to further improvements in cardiovascular outcomes.

The prevalence of chronic kidney disease among type 2 diabetes mellitus patients in central South Africa

BACKGROUND

 Type 2 diabetes mellitus (T2DM) is a leading cause of chronic kidney disease (CKD). The prevalence of CKD among T2DM patients in Africa is 22.0%. The cut-off age for dialysing diabetic patients in the resource-limited state sector in South Africa is 50 years. Type 2 diabetes mellitus patients who develop CKD are likely to be excluded from chronic dialysis and rely on control of risk factors, including blood pressure and blood glucose levels, to prevent CKD progression. We aimed to determine the prevalence of CKD among T2DM patients attending the diabetes clinic at Pelonomi Academic Hospital, Bloemfontein.

METHODS

 In this retrospective cross-sectional study, medical records of patients (January 2016 and December 2018) were reviewed to collect demographic and clinical information.

RESULTS

 In total, 244 records were reviewed. Sixty-one (25.0%, 95% confidence interval [CI]: 20% - 30.8%) T2DM patients had CKD. The rate of CKD was slightly higher in males (n = 24/81; 29.6%) compared with females (n = 37/163; 22.7%). Most patients with CKD (n = 58; 95.1%) were 50 years of age. Only 17.8% of patients achieved a glycosylated haemoglobin (HbA1c) of 7.0%. Blood pressure was controlled in 14.3% of hypertensive patients. Renin-angiotensin-aldosterone system inhibitors were used by 78.6% of patients.

CONCLUSION

 A high prevalence of clinically significant CKD among T2DM patients with poor prospects of chronic dialysis in a resource-limited setting was observed. The risk factors for CKD development and progression should be adequately managed in T2DM patients.Contribution: This study emphasises the need for further research and innovation to improve outcomes of T2DM patients with CKD in resource-constrained settings.

Relationship between plasma homocysteine and chronic kidney disease in US patients with type 2 diabetes mellitus: a cross-sectional study

AIMS

This cross-sectional study aimed to investigate the association between plasma homocysteine (Hcy) and chronic kidney disease (CKD) in US patients with type 2 diabetes mellitus (T2DM).

METHODS

We used data from the 2003-2006 National Health and Nutritional Examination Surveys (NHANES). CKD was defined as an estimated glomerular filtration rate < 60 ml/min/1.73 m² and/or urinary albumin-creatine ratio ≥ 3 mg/mmol.

RESULTS

This study included 1018 patients with T2DM. The mean Hcy value was 10.2 ± 4.6 μmol/L. Among the patients, 417 (40.96%) had hyperhomocysteinemia (HHcy) and 480 (47.15%) had CKD. The Hcy level was higher in patients with CKD than in those without CKD. Compared to patients with normal Hcy, those with HHcy were older and had worse renal function. After full multivariate adjustment, HHcy was positively associated with the risk of CKD in US patients with T2DM (OR, 1.17; 95% CI, 1.11-1.22; P <  0.001), which for women was 1.15 (95% CI, 1.08 ~ 1.23; P <  0.001) and for men was 1.18 (95% CI, 1.1 ~ 1.27; P <  0.001).

CONCLUSIONS

HHcy was independently associated with CKD in patients with T2DM. Further prospective studies are warranted to investigate the effect of Hcy on CKD in patients with T2DM.

Disparities in efficacy and safety of sodium-glucose cotransporter 2 inhibitor among patients with different extents of renal dysfunction: A systematic review and meta-analysis of randomized controlled trials

Background: The pleiotropic efficacy of SGLT2is in patients with different eGFR levels has not been well-understood. This systematic review and meta-analysis assessed the disparities in the efficacy and safety of SGLT2i treatment across stratified renal function. Methods: We searched four databases from inception to December 2021. We included randomized controlled trials (RCTs) with reported baseline eGFR levels and absolute changes from baseline in at least one of the following outcomes: HbA1c, body weight, blood pressure, and eGFR. Continuous outcomes were evaluated as the weighted mean differences (WMDs) and 95% confidence intervals (CIs). Categorical outcomes were evaluated as odds ratios (ORs) and accompanying 95% CIs. Results: In total, 86 eligible RCTs were included. SGLT2is produces a substantial benefit in glycemic control, weight control, and blood pressure control even in patients with impaired renal function. HbA1c and weight reductions observed in SGLT2i users were generally parallel with the renal function levels, although there was an augmented weight reduction in severe renal dysfunction stratum [HbA1c: -0.49% (-0.58 to -0.39%) for normal renal function, -0.58% (-0.66 to -0.50%) for mild renal function impairment, -0.22% (-0.35 to -0.09%) for moderate renal function impairment, and -0.13% (-0.67 to 0.42%) for severe renal function impairment (p < 0.001 for subgroup differences); weight: -2.12 kg (-2.66 to -1.59 kg) for normal renal function, -2.06 kg (-2.31 to -1.82 kg) for mild renal function impairment; -1.23 kg (-1.59 to -0.86 kg) for moderate renal function impairment; -1.88 kg (-3.04 to -0.72 kg) for severe renal function impairment (p = 0.002 for subgroup differences)]. However, the blood pressure reduction observed in SGLT2i users was independent of renal function. When compared with the placebo, the occurrence of hypoglycemia was more frequent in patients with favorable renal function rather than in those with substantial renal dysfunction. Conclusion: The HbA1c and body weight reductions observed in SGLT2i users were generally parallel with their baseline eGFR levels, while blood pressure reductions in SGLT2i users were independent of their baseline eGFR levels. Consistently, when compared with the placebo, hypoglycemia was more frequent in patients with favorable renal function, where the HbA1c reduction was profound.