. . . covering management of hyperglycemia in DKD, delaying the progression of DKD, and evolving renal guidelines. Remember protect your kidneys, save your heart! #MedTwitter #cardiotwitter #Nephpearls @goKDIGO pic.twitter.com/PhTUMQlUUz
— @CKD_ce (@ckd_ce) November 29, 2021
1) Welcome to our accredited #tweetorial on the evidence-based primary care management of diabetic kidney disease (#DKD). Expert faculty @drkevinfernando. Accredited for 0.5 credits: #physicians, #nurses, #pharmacists!
— @CKD_ce (@ckd_ce) November 30, 2021
3) First, a poll. An eGFR <60ml/min means that your patient:
— @CKD_ce (@ckd_ce) November 30, 2021
(a) Is more likely to have ischaemic heart disease, HF, PVD, or cerebrovascular disease
(b) May be at increased risk of sustaining a hip fracture
(c) Is at increased risk of hypoglycaemia
(d) All of the above
5) A 2014 National Diabetes Audit in the UK observed that 42.3% of those living with type 2 diabetes (T2D) were recorded as having renal disease. Diabetes worsens all outcomes of CKD similarly to those with CKD but without diabetes.
— @CKD_ce (@ckd_ce) November 30, 2021
7) He has been living with T2D for 6 years and has background of CKD stage G3b A3 and is known to your renal colleagues. He also evidence of background diabetic retinopathy, hypertension and iron deficiency anaemia
— @CKD_ce (@ckd_ce) November 30, 2021
9) On examination home BP readings average 126/70, weight 77kg, no evidence fluid overload.
— @CKD_ce (@ckd_ce) November 30, 2021
Bloods eGFR 39ml/min K 5, Ca 2.4 HbA1c 58mmol/mol Hb 121 Chol:HDL 7.4.
Urinary ACR 106mg/mmol
Poll – what do you do next?
11) Select your best answer and return tomorrow for results and more education! @EndoJournalClub @AHealthBlog @ypsendo @MedEdChat @MedEdBot @Mededucation101 @RpratleyMD @drricardocorrea @mvaduganathan @brendonneuen @vladoperkovic @AmarPut @kamleshkhunti @AbdTahrani @goKDIGO
— @CKD_ce (@ckd_ce) November 30, 2021
13) The updated @goKDIGO October 2020 guidelines (great reference document at https://t.co/DJ90jmYR7O) on #diabetes management in CKD classify CKD based on #GFR category (G1-G5) and #albuminuria category (A1-A3). pic.twitter.com/51Q9yJsoL5
— @CKD_ce (@ckd_ce) December 1, 2021
15) What about HbA1c targets in DKD? We know that tight glycaemic control reduces the risk of microvascular disease including DKD. However, there is no international consensus on glycaemic control in DKD.
— @CKD_ce (@ckd_ce) December 1, 2021
17) There is also potential harm from hypoglycaemia especially with insulin.
— @CKD_ce (@ckd_ce) December 1, 2021
In DKD HbA1c targets should be individualised to maintain a positive risk benefit ratio for the person in question. pic.twitter.com/PKoTS8Vlh0
19) When using drugs to manage hyperglycaemia in DKD remember primum non nocere – first do no harm. Avoid adverse effects such as acute kidney injury (metformin used below eGFR 30ml/min) and hypoglycaemia (both sulphonylureas and insulins)
— @CKD_ce (@ckd_ce) December 1, 2021
21) the “SADMAN” mnemonic – stop SGLT2 inhibitors, ACEI, Diuretics, Metformin, ARB & NSAIDs during acute dehydrating illness and restart once eating and drinking normally after 24-48 hours pic.twitter.com/a9NizuYWP1
— @CKD_ce (@ckd_ce) December 1, 2021
23) Please return tomorrow for more education about the management of DKD in a primary care practice. @idasgupta7 @drpatrickholmes @AmarPut @kamleshkhunti @AbdTahrani
— @CKD_ce (@ckd_ce) December 1, 2021
25) How do we delay the progression of DKD?
— @CKD_ce (@ckd_ce) December 2, 2021
The @goKDIGO guidelines suggested all with #diabetes and #CKD be treated with a comprehensive strategy to reduce risks of kidney disease progression and #CVD pic.twitter.com/bJp3eCvTdh
27) . . . Advise on smoking cessation as appropriate.
— @CKD_ce (@ckd_ce) December 2, 2021
NICE CG181 (2014) guidance suggests statins (specifically atorvastatin 20mg) for primary and secondary prevention of CVD if eGFR <60ml/min
29) Anti-platelet therapy in CKD/DKD remains contentious. Benefits for the secondary prevention of CVD are irrefutable but expert opinion varies for primary prevention. The ASCEND trial (NEJM 2018) demonstrated no net benefit for ASA for primary prevention of CVD in diabetes.
— @CKD_ce (@ckd_ce) December 2, 2021
31) . . . which demonstrated significant reductions in major adverse renal outcomes. Notably DAPA-CKD also demonstrated this in a population of individuals with CKD but WITHOUT diabetes.
— @CKD_ce (@ckd_ce) December 2, 2021
DAPA-CKD: N Engl J Med 2020; 383:1436-1446
CREDENCE: N Engl J Med 2019; 380:2295-2306
33) Similarly, @AmDiabetesAssn/@EASDnews consensus statement 2019 update Diabetes Care 2020 suggests if CKD predominates in a person living with T2D, specifically eGFR 30-60ml/min or urinary ACR >30mg/g, . . .
— @CKD_ce (@ckd_ce) December 2, 2021
35) Dapagliflozin and canagliflozin have different approved indications in the US and the UK. Currently both are reasonable evidence-based options for the management of DKD and are appropriate both for people with and without diabetes.
— @CKD_ce (@ckd_ce) December 2, 2021
37) That's it! You made it! Free CE/CME! Now go to https://t.co/yUr8zQsCMj and claim your credit! I am @drkevinfernando. Follow @ckd_CE for more #tweetorials! #medtwittter #cardiotwitter #endotwitter @MedTweetorials @cardiomet_CE
— @CKD_ce (@ckd_ce) December 2, 2021