CHAPTER 1. COMPREHENSIVE CARE IN PATIENTS WITH DIABETES AND CKD

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* By agreeing to provide feedback on this draft guideline document, you hereby permit KDIGO to acknowledge your participation as a reviewer in the final publication.

1.1. Comprehensive diabetes and chronic kidney disease management

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* Practice Point 1.1.1. Patients with diabetes and CKD should be treated with a comprehensive strategy to reduce risks of kidney disease progression and cardiovascular disease. (Figure 1)

1.2. Renin-angiotensin-aldosterone system (RAAS) blockade

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* Recommendation 1.2.1. We recommend that treatment with an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) be initiated in patients with diabetes, hypertension, and albuminuria, and that these medications should be titrated to the highest approved dose that is well tolerated (1B).

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* Practice Point 1.2.1. Consider ACEi or ARB treatment in patients with diabetes and albuminuria, but have normal blood pressure.

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* Practice Point 1.2.2. Monitor for changes in blood pressure, serum creatinine, and serum potassium within two to four weeks of initiation or increase in the dose of an ACEi or ARB. (Figure 2)

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* Practice Point 1.2.3. Continue ACEi or ARB therapy unless serum creatinine rises by more than 30% within four weeks following initiation of treatment or an increase in dose. (Figure 2)

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* Practice Point 1.2.4. Advise contraception in women who are receiving ACEi or ARB, and discontinue these agents in women who are considering pregnancy, or who become pregnant while receiving ACEi or ARBs.

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* Practice Point 1.2.5. Hyperkalemia associated with the use of an ACEi or ARB can often be managed by measures to reduce serum potassium levels rather than decreasing the dose or stopping ACEi or ARB immediately. (Figure 2)

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* Practice Point 1.2.6. Reduce the dose or discontinue ACEi or ARB in the setting of symptomatic hypotension, uncontrolled hyperkalemia despite medical treatment outlined in Practice Point 1.2.5., or while preparing for imminent kidney replacement therapy.

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* Practice Point 1.2.7. Use only one agent at a time to block the RAAS. The combination of an ACEi with an ARB, or the combination of an ACEi or ARB with a direct renin inhibitor, is potentially harmful.

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* Practice Point 1.2.8. Mineralocorticoid receptor antagonists are effective for management of refractory hypertension but may cause decline in kidney function or hyperkalemia, particularly among patients with low eGFR.

1.3. Smoking cessation

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* Recommendation 1.3.1. We recommend advising patients with diabetes and CKD who use tobacco to quit using tobacco products (1D).

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* Practice Point 1.3.1. Physicians should counsel patients with diabetes and CKD to reduce second-hand smoke exposure.

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