Research around CKD and diabetes is evolving quickly.  Because of this, KDIGO recently published an update to the Diabetes and Kidney Disease Guideline just 2 years after its previous update in 2022.  Diabetic kidney disease is the leading cause of kidney failure.¹ It is hoped that a review of these new updates and guidelines can help nephrology providers better support and outcomes for their diabetic patients.

Both the 2020 and 2022 guidelines state that those with diabetes and CKD should receive a comprehensive and a holistic strategic approach to their care.^1,2 It should be noted that the term “holistic” as used here in the guidelines is not referring to using alternative therapies as is commonly thought, but to have a team of providers that can collectively address multiple needs of the patient with diabetic CKD. This would include nutrition counseling, psychosocial support, patient education and empowerment, and regular communication from the various providers on their consistent and structured assessments of risk factors, complications, psychological stress, nutrition, drug adherence and self-monitoring.¹ In clinical practice this might mean doctors’ offices expanding staff to include dietitians and social workers to have a more well-rounded team, much like the interdisciplinary team found in dialysis units. Where this is not possible, regular referrals to providers not currently present in the office with a process for regular communication could also serve this patient population well.

In diabetes as well as in kidney disease, the role of supporting heart health is increasingly coming to the forefront of clinical guidelines. The 2022 guidelines have updated the approach for kidney-heart risk factor management and recommends weight management as a foundational lifestyle and self-management point, and moved lipid management, glycemic and blood pressure control into the additional risk factor control category. This shift doesn’t change the importance or priority of these additional controls for risk factors, but rather clarifies best approaches for the individual patient once the foundational pieces of diet, exercise, weight, and smoking cessation are implemented, as well as the individualized recommendations for first-line drug therapy and medications for additional heart and kidney protection.¹

Regarding protein recommendations, the current (and previous) guidelines recommend 0.8g/kg/d for those with CKD not on dialysis and 1.0-1.2g/kg/d for those on dialysis.¹ This was primarily based on concerns for malnutrition, not for blood sugar management. Additionally, noting a lack of clinical trials on protein intake, the KDIGO workgroup based their recommendations on the current World Health Organization guidelines for protein intake for the general population.¹ However, more recent updated systematic reviews and meta-analyses indicate that diabetic patients with CKD who consumed <0.8g/kg/d experienced no signs of malnutrition while benefiting from improvement in cholesterol levels, proteinuria, and blood glucose control.³ This recommendation certainly warrants consistent review of the literature, even before more guidelines are updated to ensure the most appropriate care for diabetic CKD patients. Further, a dietitian trained in low-protein diets or very-low-protein diets for patients with CKD can provide valuable support to diabetic kidney patients looking for conservative kidney disease management, thus balancing the nutrition needs of the kidney disease and diabetes.

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The previous KDIGO nutrition guideline for the dietary pattern stands, that is, an individualized diet high in fruits, vegetables, whole grains, fiber, legumes, plant-based proteins, unsaturated fats and nuts, and low in processed meats, refined carbohydrates, and sweetened beverages.^1,2 This is in harmony with many of the more recent publications eschewing the strict nutrient restrictions of the traditional renal diet and embracing heart healthy, whole foods diets, such as the Mediterranean diet.⁴  This is likely a relief to many health care providers and patients alike, as the conflicting diets have led to much frustration, confusion, and increased burden on patients who are simultaneously trying to follow renal and diabetic diets.

The 2022 KIDGO guidelines continue to recommend the use of continuous glucose monitors (CGMs) to support glucose control.¹ CGMs can be instrumental in identifying other factors impacting glucose levels, such as: sleep, stress, food sensitivities, timing of meals and fiber intake. This provides highly individualized approaches that naturally allow for an   interdisciplinary or holistic care approach. CGMs can also help with the overall goal of self-monitoring, patient education and empowerment.

The 2022 KDIGO guidelines are a significant step forward in treating chronic disease by considering the whole person, advocating for individualized care, and encouraging interdisciplinary cooperation and patient empowerment.  As providers incorporate these guidelines into clinical practice, we will be better able to see the benefits of these approaches as well as other ways to adjust which helps to improve the lives and outcomes of those with diabetic kidney disease.

References

1. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2022;102(5S):S1-S127. doi:10.1016/j.kint.2022.06.008
2. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2020;98(4S):S1-S115. doi:10.1016/j.kint.2020.06.019