Thread by @ckd_ce

1) Welcome to a new #accredited #tweetorial from our good friends and #diabetes experts @GoggleDocs, specifically @drkevinfernando, @drpatrickholmes, & @AmarPut. They have put their 🗣️s together to provide us with a summary of the first-ever consensus statement from ...

2) ... @AmDiabetesAssn & @goKDIGO, which were discussed at the recently concluded #isnwcn congress in Kuala Lumpur. This joint document nicely summarizes important recent advances and practice-changing data for the management of diabetic #kidneydisease #DKD.

3) This program is #accredited for CE/#CME #physicians #physicianassociates #nurses #pharmacists #nursepractitioners & is supported by an independent educational grant from the Boehringer Ingelheim/Lilly Alliance. It is not intended for US based healthcare professionals.

4) So . . . Much is changing in the management of #CKD, particularly if the person #CKD has any type of #diabetes. It's a new year and a new guideline from @goKDIGO, this time in consensus with @ADA_DiabetesPro.
👉In this 🧵we will look at what's new!
#CaReMe #NephTwitter

5) As above, this collaboration is welcome and is a big deal!
(slide courtesy of @KatherineTuttl8)

6) Before look what's new in the consensus report.
Let's remember why #CKD is important to people living with any type of #diabetes
#CardioTwitter @MedTweetorials @CardioNerds @CardRenalForum

7) #CKD in #diabetes is:
📍Common
👉 ~30% #T1D
👉 ~40% #T2D
🔓cjasn.asnjournals.org/content/12/12/…
📍Increasing in prevalence due to ⤴️ people living with #diabetes & ⤴️duration of diabetes
👉Look at what’s going to happen in Africa/Middle East

8) It's serious too
Most of diabetes-associated excess CVD risk occurs in those with #CKD ‼️

9) #CKD amplifies the #CVD risk in people living #T2D
📍1 in 2 die from CVD
📍 1 in 3 die from infections/sepsis
📍only 1 in 10 die from kidney failure itself
(Thanks again @KatherineTuttl8)

10) In 2020 @goKDIGO released its Clinical Practice Guideline for Diabetes Management in #CKD with:
1) Foundation of comprehensive lifestyle
2) Goal directed therapy for BP, #Lipids & Glucose
3) Targeted therapy (RAS & #SGLT2i drugs)
4) #antiplatelets for eASCVD

11) Evidence is changing fast❗️
Since the 2020 guidance the evidence has changed with the publication of studies using the following drug classes
📍#SGLT2i #flozins
📍#GLP-1 Receptor Agonists (GLP-1ra)
📍Mineralocorticoid Receptor Antagonists (#MRA)

12) What the heck are Non-steroidal & Steroidal Mineralocorticoid Receptor Antagonists (#MRAs)?

Check out this 🧵
👇

https://twitter.com/ckd_ce/status/1493567221599293441?s=20&t=4AbFG4J09-wuJRgFRMS3rA

and earn even MORE 🆓CE/#CME from the growing course library at ckd-ce.com/category/mra/.
That may help clear up any . . .

13) Before we go on to recommendations and data behind them, a quick quiz

Approximately what proportion with #T2D plus #CKD die from cardiovascular diseases? Mark your answer before you scroll ⤵️!

14) It's D--WOW!
At the❤️of the ADA-KDIGO consensus statement is a holistic approach managing all risk factors.

Note what's new
📍Weight management
📍SGLT2i now with a lower eGFR cutoff
📍Non-steroidal MRAs for persistent albuminuria
📍Enhanced lipid management #icosapentethyl

15) Let’s take a deeper dive in to the rationale behind the headlines

16) Why is weight mgmt in the guideline?
📍Secondary analysis of the Look AHEAD RCT indicated Intensive lifestyle intervention was associated with a 27%⤵️in the development of high risk #CKD
📍Effects attributable to:
⤵️bodyweight
⤵️HbA1c
⤵️BP
And then there’s pharmacotherapy:

17) What are the new recommendations for use in #SGLT2i?
📍Initiation threshold of SGLT2i ⤵️ to an eGFR of 20❗️, based on #EMPEROR studies
📍Continue SGLT2i til dialysis‼️, as per #CREDENCE & #DAPA-CKD trials

18) So are you paying attention??
2022 @goKDIGO Diabetes & CKD recommends initiating SGLT2i above what eGFR value?

19) Safety first. For SGLT2i’s

📍Helpful guide in selecting patients 😊

📍Recommendations to
⤵️Risk of DKA ⚠️
⤵️Hypoglycaemia⚠️
⤵️volume depletion⚠️

👇👇👇

20) What's new in the use of #GLP-1ra's in CKD?

📍new data & meta-analysis added (AMPLITUDE-O)

📍recommendation remains: For glycemic management after metformin & SGLT2i

📍New weight-loss practice point added: "GLP-1ra are effective agents for weight loss in T2D + CKD"

21) What about the kid on the block, non-steroidal MRA (#finerenone)?

📍non-steroidal MRA recommended: In pts on max tolerated ACEi/ARB w/ eGFR ≥ 25, normal potassium, & persistent albuminuria

📍In general SGLT2i initiated prior to finerenone

Rationale comes from 3 trials

22) Those 3⃣ are
👉FIDELIO-DKD
👉FIGARO-DKD
👉 FIDELITY (pooled analysis)
📍sub-group analysis indicates benefit of finerenone is additive to SGLT2i

Learn more about this from @drkevinfernando on this thread

https://twitter.com/ckd_ce/status/1483778724180938752?s=20&t=4AbFG4J09-wuJRgFRMS3rA

23) And a composite slide from @KatherineTuttl8, for those of you who prefer all-you-can-eat dining!

24) Using non-steroidal MRA's safely

📍Serum creatinine & potassium should monitored
📍If eGFR ⤵️ ≥ 30% then STOP❗️
📍If potassium ≥ 5.5 mol/l then STOP‼️

25) The @goKDIGO 2022 guidance offers a new pyramid of care
📍Foundation of intensive lifestyle interventions (including weight)
📍Targeted first -line therapy (metformin, SGLT2i, RASi & statins)
📍Goal-directed therapy depending on response

26) The overall aim would be to

⤵️ Kidney function decline
⤵️ Cardiovascular morbidity & mortality
⤴️ Quality & length of life

27) To read more about the @goKDIGO guideline please check out their website
kdigo.org/guidelines/dia…

28) And always follow dosing guidelines and comorbidity considerations for these new drugs that can have such dramatic impact!

29) And that's it! You've made it and you are UP TO DATE! Go to ckd-ce.com/dkd6/ to claim your CE/#CME credit thanks to @GoggleDocs & @academiccme. And please follow @ckd_ce and @cardiomet_CE for the BEST updates and education from the BEST faculty!