Linking To And Excerpting From The Curbsiders’ “#454 Kidney Boy on Managing Diabetes and Hypertension in CKD”

In addition to today’s resource, please review

Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117–S314. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF].

In addition to today’s resource, please review The Cribsiders “#112: The Re(n)al Truth Behind Proteinuria”*
Posted on June 26, 2024 by Tom Wade MD

*Wilson S, Zangla E, Kouri A, Masur S, Chiu C, Berk J. “#112: The Re(n)al Truth Behind Proteinuria”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ June 19, 2024.

Today, I review, link to, and excerpt from The Curbsiders‘ “#454 Kidney Boy on Managing Diabetes and Hypertension in CKD“.*

*Syed F, Williams PN, Surani Z, Achi S, Watto MF. “#454 Kidney Boy on Managing Diabetes and Hypertension in CKD”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing September 23, 2024.

All that follows is from the above resource.

 

Here is the link to the show notes.

All that follows is from the above show notes.

DM, HTN, CKD Pearls

1. Albuminuria is an important factor in classifying chronic kidney disease (CKD) and determining renal prognosis.
2. Cystatin C is a more reliable marker of kidney function than creatinine and can help in categorizing patients with CKD.
3. ACE inhibitors and ARBs should not be discontinued solely based on glomerular filtration rate (GFR) in patients with CKD, as they provide renal and cardiovascular benefits.
4. Blood pressure management is critical in CKD, and achieving target blood pressure may require a combination of medications.
5. Hyperkalemia can be managed with potassium binders, allowing patients to continue using ACE inhibitors or ARBs, which are beneficial in CKD.
6. Diuretics, SGLT2 inhibitors, and mineralocorticoid receptor antagonists can be used in CKD patients with heart failure to manage blood pressure and improve outcomes.
7. Individualized treatment plans for patients with advanced CKD should account for comorbidities like diabetes and heart failure.
8. Blood pressure management in dialysis patients should be based on non-dialysis day measurements, such as ambulatory or home readings.
9. In patients with advanced CKD and diabetes on dialysis, glycemic control may be relaxed, but blood pressure control remains important to prevent complications.

DM, HTN, CKD Definitions

Definitions

CKD Staging

Guidelines Summary:

The most recent CKD (Chronic Kidney Disease) classification guidelines from KDIGO (Kidney Disease: Improving Global Outcomes) classify CKD based on GFR (glomerular filtration rate) and albuminuria, along with the underlying cause of CKD. These guidelines help predict kidney disease progression and associated risks. Here’s a breakdown:

1. GFR Categories (G-Stages)

CKD is classified into six categories based on GFR:

• G1: GFR ≥ 90 mL/min/1.73 m² (normal or high)
• G2: GFR 60-89 mL/min/1.73 m² (mildly decreased)
• G3a: GFR 45-59 mL/min/1.73 m² (mildly to moderately decreased)
• G3b: GFR 30-44 mL/min/1.73 m² (moderately to severely decreased)
• G4: GFR 15-29 mL/min/1.73 m² (severely decreased)
• G5: GFR < 15 mL/min/1.73 m² (kidney failure, often requiring dialysis)

2. Albuminuria Categories (A-Stages)

CKD is also classified based on the albumin-to-creatinine ratio (ACR) in milligrams per gram (mg/g):

• A1: ACR < 30 mg/g (normal to mildly increased)
• A2: ACR 30-300 mg/g (moderately increased, also called microalbuminuria)
• A3: ACR > 300 mg/g (severely increased, also called macroalbuminuria)

3. Risk Assessment Classification Table: Combining GFR and Albuminuria

The CKD stage is determined by combining the GFR and albuminuria categories, where higher risk of progression is seen in lower GFR and higher albuminuria:

GFR Category	Albuminuria (A1: <30 mg/g)	Albuminuria (A2: 30-300 mg/g)	Albuminuria (A3: >300 mg/g)
G1	Low risk	Moderate risk	High risk
G2	Low risk	Moderate risk	High risk
G3a	Moderate risk	Moderate risk	Very high risk
G3b	High risk	High risk	Very high risk
G4	Very high risk	Very high risk	Very high risk
G5	Kidney failure (treatment based on symptoms)	Kidney failure	Kidney failure

4. Other Key Points

• Cause of CKD: The underlying cause of CKD (e.g., diabetes, hypertension, glomerulonephritis) is also factored into prognosis and management but is not part of the numerical classification.
• Prognosis: CKD staging helps predict the risk of progression to kidney failure, cardiovascular events, and mortality, guiding treatment strategies like blood pressure control, diabetes management, and use of medications like ACE inhibitors or ARBs.

Kashlak Pearl This GFR and albuminuria-based classification helps stratify patients into different risk categories, informing clinical decisions and management.

Managing HTN in CKD

Dr. Topf mentions don’t undertreat blood pressure in order to preserve GFR.   Remember that HTN is probably an underlying cause of renal dysfunction.  So do not undertreat blood pressure to keep a lab value from getting worse.  Consider switching to more potent diuretics like switching HCTZ to chlorthalidone.  Telmisartan is a good drug for HTN.  Make changes in a stepwise fashion, not all at once.  Don’t be afraid of using potassium binders to treat hyperkalemia associated with some medications.  The bottom line is to keep blood pressure in check.

Managing DM in CKD

The same advice for HTN applies for DM.  Tight glycemic control helps reduce progression, so control the diabetes.  SGLT2is are safe to use.

Managing HTN in CKD

Dr. Topf mentions don’t undertreat blood pressure in order to preserve GFR.   Remember that HTN is probably an underlying cause of renal dysfunction.  So do not undertreat blood pressure to keep a lab value from getting worse.  Consider switching to more potent diuretics like switching HCTZ to chlorthalidone.  Telmisartan is a good drug for HTN.  Make changes in a stepwise fashion, not all at once.  Don’t be afraid of using potassium binders to treat hyperkalemia associated with some medications.  The bottom line is to keep blood pressure in check.

Managing DM in CKD

The same advice for HTN applies for DM.  Tight glycemic control helps reduce progression, so control the diabetes.  SGLT2is are safe to use.

Managing HTN and DM in ESRD

Treat the patient based on their non dialysis days.  Aces/ARBc, Calcium channel blockers, aldactone and beta blockers are all safe to continue in dialysis patients.  If a patient is requiring midodrine to get through dialysis, there is probably some component of  heart failure involved.