#454 Kidney Boy on Managing Diabetes and Hypertension in CKD

September 23, 2024 | By Fatima Syed

Audio

Video

Transcript available via YouTube

Learn how to manage diabetes and hypertension in chronic kidney disease with expert tips from Kidney Boy, Kashlak’s Chief of Nephrology, Dr. Joef Topf @kidney_boy. 

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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner, Picks of the Week*
• Case from Kashlak; Definitions
• Classifications of CKD
• Risk Assessment and Progression of CKD
• Lab Assessments of Renal Function
• Managing HTN in patients with CKD
• DM Management in patients with CKD
• Managing HTN and DM in patients on dialysis
• Outro

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:

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.  

Finerenone is FDA approved for managing CKD in patients with diabetes. **Update as of July 2025: The non-steroidal mineralocorticoid recepter antagonist, finerenone is now FDA approved to treat heart failure with LVEF at or above 40% based on results of the FINEARTS-HF trial. **

Managing HTN and DM in ESRD

Treat the patient based on their non dialysis days.  Aces/ARBc, Calcium channel blockers, mineralocorticoid receptor antagonists (spironolactone, eplerenone), 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.  

Links

Trials and Guidelines mentioned:

CLICK Trial (Chlorthalidone in Chronic Kidney Disease)

• This study focused on the effects of chlorthalidone, a thiazide diuretic, in patients with stage 4 chronic kidney disease (CKD) and uncontrolled hypertension. Conducted as a double-blind, placebo-controlled trial, it found that chlorthalidone significantly reduced systolic blood pressure by 11 mmHg over a 12-week period compared to placebo. However, it also noted potential adverse effects, including reversible increases in kidney function markers. This study was presented at the American Society of Nephrology’s Kidney Week 2021.
• Source: HCP Live (HCP Live)

CRIC Study (Chronic Renal Insufficiency Cohort Study)

• The CRIC study is one of the largest and longest ongoing studies on CKD in the U.S., aimed at identifying the causes and consequences of CKD and its link to cardiovascular disease. It has contributed significant findings, such as the association between high fibroblast growth factor 23 (FGF 23) levels and increased kidney failure risk, and the role of the APOL1 gene in African Americans.
• Source: NIDDK (NIDDK)

STOP ACE Trial

• The STOP-ACE (Angiotensin Converting Enzyme) trial assessed the discontinuation of ACE inhibitors in patients with advanced CKD. It evaluated whether stopping ACE inhibitors might improve kidney outcomes in certain high-risk populations. Results suggested that stopping ACE inhibitors did not lead to improved outcomes and that they should generally be continued in most cases.
• Source: NEJM 

Goal

Listeners will develop a framework to approach management of diabetes and hypertension in CKD.

Learning objectives

After listening to this episode listeners will…

1. Define CKD, define the difference between CKD and ESRD, and understand the nuance in care goals of both populations 
2. Learn how to manage HTN in this population
3. Learn how to manage DM2 and CHF in this population
4. Learn how to manage bone health and osteoporosis in this population

Disclosures

Dr Topf reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

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.