The European Renal Best Practice (ERBP) group published the “Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min) online ahead of print in Nephrology Dialysis Transplantation.
“The guideline intends to provide an evidence-based rationale and, thus, to facilitate informed decision-making on the management of adult patients with diabetes mellitus and CKD”, explains Professor Wim Van Biesen, chair of European Renal Best Practice. “A patient with diabetes and CKD has to be treated differently than a non-CKD patient with diabetes. Two things, especially, are important here: The adaptation of medication to renal function and, second, the consideration of the much higher risk for hypoglycemia in patients without chronic kidney disease. Therefore I believe, the guideline is very relevant and will have future impact.”
The guidelines cover issues such as dialysis modality choice, vascular access, glycemic control, and transplant options.
The guidelines recommend living donation kidney transplantation or simultaneous pancreas kidney transplantation in patients with type 1 diabetes and stage 5 CKD. For type 2 diabetes patients seeking a kidney transplant, the guidelines said "we recommend diabetes per se should not be considered a contraindication to kidney transplantation in patients who otherwise comply with inclusion and exclusion criteria for transplantation."
The guidelines do not recommend tighter glycemic control if it can result in sever hypoglycemic episodes. They recommend vigilant attempts to tighten glycemic control with the intention to lower HbA1C when values are >8.5% (69 mmol/mol). and intense intense self-monitoring only to avoid hypoglycemia in patients at high risk for hypoglycemia.
Dialysis modality choice
The guidelines recommend "giving priority to the patient's general status and preference in selecting renal replacement therapy as there is an absence of evidence of superiority of one modality over another in patients with diabetes and CKD stage 5. In patients opting to start hemodialysis, we suggest preferring high flux over low flux when this is available."
Read the full guidelines.