Special Section
KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 Update

https://doi.org/10.1053/j.ajkd.2012.07.005Get rights and content

Abstract

The 2012 update of the Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Diabetes and Chronic Kidney Disease (CKD) is intended to assist the practitioner caring for patients with diabetes and CKD. Substantial high-quality new evidence has emerged since the original 2007 KDOQI guideline that could significantly change recommendations for clinical practice. As such, revisions of prior guidelines are offered that specifically address hemoglobin A1c (HbA1c) targets, treatments to lower low-density lipoprotein cholesterol (LDL-C) levels, and use of angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blocker (ARB) treatment in diabetic patients with and without albuminuria. Treatment approaches are addressed in each section and the stated guideline recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Limitations of the evidence are discussed and specific suggestions are provided for future research.

Section snippets

Section I: Use of the Clinical Practice Guideline

This Clinical Practice Guideline is based upon a systematic literature search that included articles published through October 2010 and upon the best information available from relevant newer publications and scientific presentations through April 2012. It is designed to provide information and assist decision making. It is not intended to define a standard of care, and should not be construed as one, nor should it be interpreted as prescribing an exclusive course of management. Variations in

Work Group Membership

Work Group Co-Chairs
Robert G. Nelson, MD, PhD
National Institutes of Health
Phoenix, AZ, USA
Katherine R. Tuttle, MD, FASN, FACP
Providence Medical Research Center
University of Washington School of Medicine
Spokane, WA, USA

Work Group
Rudolph W. Bilous, MD
The James Cook University Hospital
Middlesbrough, UK
J. Michael Gonzalez-Campoy, MD, PhD, FACE
Minnesota Center for Obesity, Metabolism and Endocrinology, PA (MNCOME)
Eagan, MN, USA
Michael Mauer, MD
University of Minnesota Medical School
Minneapolis, MN,

KDOQI Leadership

Michael V. Rocco, MD, MSCE

KDOQI Chair

Jeffrey S. Berns, MD

Vice Chair, Guidelines and Commentary

Joseph V. Nally, Jr, MD

Vice Chair, Public Policy

Holly Kramer, MD

Vice Chair, Research

Michael J. Choi, MD

Vice Chair, Education

NKF-KDOQI Guideline Development Staff

Kerry Willis, PhD, Senior Vice-President for Scientific Activities

Emily Howell, MA, Communications Director

Michael Cheung, MA, Guideline Development Director

Sean Slifer, BA, Guideline Development Manager

Table of Contents

Abbreviations and Acronyms855
Reference Keys856
Foreword857
Executive Summary858
Summary of Recommendations861
Guideline 2: Management of Hypergylcemia and General Diabetes Care in CKD862
Guideline 4: Management of Dyslipidemia in Diabetes and CKD868
Guideline 6: Management of Albuminuria in Normotensive Patients with Diabetes873
Research Recommendations875
Conclusion877
Acknowledgements878
Biographic and Disclosure Information879
References883

Tables

Table 1. Grade for Strength of Recommendation in the Diabetes and CKD Guideline859
Table 2. Grade for Quality of Evidence in the Diabetes and CKD Guideline860
Table 3. Target and Achieved HbA1c Levels in the Intensively and Conventionally Treated Groups of Three Recent Clinical Trials that Examined Different Levels of Glycemic Control in Patients with Type 2 Diabetes863
Table 4. Dose Adjustment for Insulin Compounds and Oral Medicines for Diabetes in CKD865
Table 5. Summary of Four Post Hoc Analyses

Figure

Figure 1. Key Questions (KQ) to Be Addressed By the Evidence Review858

Abbreviations and Acronyms

4DDeutsche Diabetes Dialyse Studie
4SScandinavian Simvastatin Survival Study
ACCORDAction to Control Cardiovascular Risk in Diabetes
ACEAngiotensin-converting enzyme
ACE-IAngiotensin-converting enzyme inhibitor
AdDITAdolescent type 1 Diabetes cardio-renal Intervention Trial
ADVANCEAction in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation
ALERTAssessment of Lescol in Renal Transplant
ALTITUDEAliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal

CKD Nomenclature Used by KDOQI

CKD CategoriesDefinition
CKDCKD of any stage (1-5), with or without a kidney transplant, including both non–dialysis dependent CKD (CKD 1–5ND) and dialysis-dependent CKD (CKD 5D)
CKD NDNon–dialysis-dependent CKD of any stage (1-5), with or without a kidney transplant (i.e., CKD excluding CKD 5D)
CKD TNon–dialysis-dependent CKD of any stage (1-5) with a kidney transplant
Specific CKD Stages
CKD 1, 2, 3, 4Specific stages of CKD, CKD ND, or CKD T
CKD 3-4, etc.Range of specific stages (e.g., both CKD 3

Foreword

This publication of the Kidney Diseases Outcomes Quality Initiative (KDOQI) updates several areas of the 2007 KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. The need for this update was the result of increasing recognition that substantial high-quality new evidence had become available since 2007 that could significantly change recommendations for clinical practice. Using the usual rigorous analytical methods of the KDOQI

Summary of Recommendations

Guideline 2: Management of Hyperglycemia and General Diabetes Care in CKD

Hyperglycemia, the defining feature of diabetes, is a fundamental cause of vascular target organ complications, including diabetic kidney disease (DKD). Intensive treatment of hyperglycemia prevents elevated albuminuria or delays its progression, but patients treated by approaches designed to achieve near normal glycemia may be at increased risk of severe hypoglycemia. Evidence that intensive treatment has an effect on

Guideline 2: Management of Hyperglycemia and General Diabetes Care in CKD

Hyperglycemia, the defining feature of diabetes, is a fundamental cause of vascular target organ complications, including diabetic kidney disease (DKD). Intensive treatment of hyperglycemia prevents elevated albuminuria or delays its progression, but patients treated by approaches designed to achieve near normal glycemia may be at increased risk of severe hypoglycemia. Evidence that intensive treatment has an effect on loss of glomerular filtratin rate (GFR) is sparse.

  • 2.1

    We recommend a target HbA

Guideline 4: Management of Dyslipidemia in Diabetes and CKD

Dyslipidemia is common in people with diabetes and CKD. Cardiovascular events are a frequent cause of morbidity and mortality in this population. Lowering low-density lipoprotein cholesterol (LDL-C) with statin-based therapies reduces risk of major atherosclerotic events, but not all-cause mortality, in patients with CKD including those with diabetes.

  • 4.1

    We recommend using LDL-C lowering medicines, such as statins or statin/ezetimibe combination, to reduce risk of major atherosclerotic events in

Guideline 6: Management of Albuminuria in Normotensive Patients with Diabetes

Treatments that produce a lasting decrease in urinary albumin excretion may slow the progression of DKD even in the absence of hypertension. However, most people with diabetes and albuminuria have hypertension. Assessment of albuminuria is addressed in Guideline 1.4 Management of hypertension is addressed in Guideline 34 and the KDIGO Clinical Practice Guideline for the Management of Blood Pressure in CKD.

  • 6.1

    We recommend not using an angiotensin-converting enzyme inhibitor (ACE-I) or an

Research Recommendations

These guideline updates, and the clinical trials on which they were based, illustrate the importance of continuing to conduct research that challenges or expands established clinical practice. As stated in the original guideline, uncertainty is an immutable element of all scientific research, and the establishment of a guideline should neither preclude nor render unethical further inquiry.4 Even as knowledge regarding approaches to managing diabetes to prevent or treat DKD and related

Conclusion

Earlier and more aggressive therapeutic intervention is believed to be responsible, at least in part, for the general decline in the incidence of ESRD attributable to diabetes among several racial and ethnic groups in recent years.2 Encouraged by these observations and by the results of previous trials using less aggressive endpoints, several large, well-designed clinical trials were conducted among patients with diabetes to determine whether even earlier or more intensive therapy might further

Acknowledgements

Guideline recommendations included in this Update were published originally in the American Journal of Kidney Diseases in 2007 and were reproduced with permission from the NKF.

We thank Drs Michael Rocco and Jeffrey Berns for their careful review of this manuscript; and Kerry Willis, Emily Howell, and Michael Cheung from the National Kidney Foundation for help coordinating the work of the group and preparing the manuscript.

The Work Group is indebted to the evidence review team from the

Biographic and Disclosure Information

Rudolf W. Bilous, MD, is Professor of Clinical Medicine at Newcastle University and Honorary Consultant Physician at the James Cook University Hospital, Middlesbrough, UK. He studied medicine at Guy's Hospital and completed his clinical training at various hospitals in London. He was an NIH Fellow at the Unit for Metabolic Medicine at Guy's from 1980-1982 working for Professor Harry Keen and with Drs John Pickup and Giancarlo Viberti examining the effects of metabolic control on microvascular

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