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DKD Toolkit

State-of-the-Art Treatment of DKD

Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2024 
The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care.


KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
"The aim [of this guideline] is to assist clinicians caring for people with CKD, both adults and children. People receiving dialysis and kidney transplant recipients are not the focus of this guideline. The scope includes chapters dedicated to the evaluation of CKD, risk assessment in people with CKD, management to delay CKD progression and manage its complications, medical management and drug stewardship in CKD, and optimal models of CKD care."

CDC: Chronic Kidney Disease Initiative 
CKD has varying levels of seriousness. It usually gets worse over time though treatment has been shown to slow progression. If left untreated, CKD can progress to kidney failure and early cardiovascular disease. 


Shubrook JH, et al. Management of chronic kidney disease in type 2 diabetes: screening, diagnosis and treatment goals, and recommendationsPostgrad Med. 2022;134(4):376-387

Agarwal R, Fouque D, The foundation and the four pillars of treatment for cardiorenal protection in people with chronic kidney disease and type 2 diabetesNephrol Dial Transplant. 2023;38(2):253-257

Heerspink HJL, et al. Estimated lifetime benefit of novel pharmacological therapies in patients with type 2 diabetes and chronic kidney disease: A joint analysis of randomized controlled clinical trialsDiabetes Obes Metab. 2023, Nov;25(11):3327-3336.

Nee R, et al. Overcoming barriers to implementing new guideline-directed therapies for chronic kidney diseaseNephrol Dial Transplant. 2023 Feb 28;38(3):532-541.


Clinical Application of Incretin-Based Therapy: Therapeutic Potential, Patient Selection and Clinical Use 
Incretin-based therapies address the progressive nature of type 2 diabetes mellitus, not only by addressing glucose control but also with weight-neutral and weight-reducing effects. Preclinical data suggest that incretin-based therapies may also preserve beta-cell function, holding promise of a truly disease-modifying therapy.

High cardiovascular risk in patients with Type 2 diabetic nephropathy: the predictive role of albuminuria and glomerular filtration rate. The NID-2 Prospective Cohort Study 
In patients with Type 2 diabetes, clinical diagnosis of diabetic nephropathy (DN) is generally based on the concomitant presence of abnormal albuminuria and severe retinopathy. A clinically based diagnosis of DN in Type 2 diabetes allows the identification of subjects with high CV risk. Albuminuria has a relevant prognostic effect on CV morbidity and mortality; its effect is especially pronounced when GFR is normal or near normal. 

Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999 
Knowledge of the excess risk posed by specific cardiovascular syndromes could help in the development of strategies to reduce premature mortality among patients with chronic kidney disease (CKD). 

Kidney Disease and Increased Mortality Risk in Type 2 Diabetes  
Type 2 diabetes associates with increased risk of mortality, but how kidney disease contributes to this mortality risk among individuals with type 2 diabetes is not completely understood. This study examines 10-year cumulative mortality by diabetes and kidney disease status for 15,046 participants in the Third National Health and Nutrition Examination Survey (NHANES III) by linking baseline data from NHANES III with the National Death Index. 


Management of chronic kidney disease in type 2 diabetes: screening, diagnosis and treatment goals, and recommendations 
The increasing number of people with CKD and T2D will ultimately have a significant impact upon health resource use and costs of care for people with T2D. Management of CKD in patients with T2D aims to preserve kidney function to reduce the risk of end-stage kidney disease, CV events, and mortality.


Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) 
A joint group of ADA and KDIGO representatives reviewed and developed a series of consensus statements to guide clinical care. 


Chronic Kidney Disease Testing Among At-Risk Adults in the U.S. Remains Low: Real-World Evidence From a National Laboratory Database 
An estimated 37 million Americans have chronic kidney disease (CKD). Nearly 90% do not know about their condition because of low awareness about the importance of CKD testing and diagnosis among practitioners and people at risk for CKD. This study uses data from a national clinical laboratory to identify guideline-recommended CKD testing rates across the U.S. .


REVEAL CKD: Estimated Glomerular Filtration Rate (eGFR) Decline Before and After a CKD Diagnosis Among Patients With CKD Stage 3 (PDF link: depending on browser settings, link will either open in new window or download to your computer. Reference on page 304)
Studies have shown considerably high rates of undiagnosed early-stage CKD despite guidelines recommending that CKD should be diagnosed and managed as soon as possible to slow progression and prevent complications. However, the benefit of an early diagnosis is not yet fully understood. The aim of this analysis was to describe the potential change in slope of eGFR before and after a CKD diagnosis using data from the REVEAL-CKD study program. 


Glycemic Targets: ADA Standards of Care in Diabetes-2024
Glycemic control is assessed by the A1C measurement, continuous glucose monitoring (CGM) using time in range (TIR) and/or glucose management indicator (GMI), and blood glucose monitoring (BGM). For many people with diabetes, glucose monitoring is key for achieving glycemic targets, 

Cardiovascular Disease and Risk Management: ADA Standards of Care in Diabetes—2024
Atherosclerotic cardiovascular disease (ASCVD)—defined as coronary heart disease (CHD), cerebrovascular disease, or peripheral arterial disease presumed to be of atherosclerotic origin—is the leading cause of morbidity and mortality for individuals with diabetes and results in an estimated $37.3 billion in cardiovascular-related spending per year associated with diabetes. 

Tirzepatide Prescribing Information (PDF link: 
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Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. 

Mineralocorticoid Receptor Antagonists: a Comprehensive Review of Finerenone 
MRAs are well known for their utility in treating heart failure, refractory hypertension, and diverse nephropathies, namely, diabetic nephropathy. As their name denotes, MRAs inhibit the action of aldosterone at the mineralocorticoid receptor, preventing receptor activation. Specifically, finerenone is a new medication that is currently under investigation for its promising cardiovascular and nephrological effects. 


Effects of Mineralocorticoid Receptor Antagonists in Proteinuric Kidney Disease 
Reductions in albuminuria of more than 30% are considered a strong marker of delay of chronic kidney disease (CKD) progression. Single renin–angiotensin system (RAS) blockade represents the cornerstone of CKD treatment. However, as CKD progression still occurs, other nephroprotective options were explored; mineralocorticoid receptor antagonists (MRA) were tested with generally positive results. 

Steroidal and non-steroidal mineralocorticoid receptor antagonists in cardiorenal medicine 
Among patients with Type 2 diabetes, several Phase II studies of finerenone show promising results, supporting benefits on the heart and kidneys. Furthermore, finerenone significantly reduced the combined primary endpoint (chronic kidney disease progression, kidney failure, or kidney death) vs. placebo when added to the standard of care in a large Phase III trial. 

Investigating new treatment opportunities for patients with chronic kidney disease in type 2 diabetes: the role of finerenone 
Despite the standard of care, patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) progress to dialysis, are hospitalized for heart failure and die prematurely. Overactivation of the mineralocorticoid receptor (MR) causes inflammation and fibrosis that damages the kidney and heart. Finerenone, a nonsteroidal, selective MR antagonist, confers kidney and heart protection in both animal models and Phase II clinical studies.

Finerenone Prescribing Information (PDF link: 
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Finerenone is indicated as an adjunct to standard of care therapy in adults with chronic kidney disease (CKD) and type 2 diabetes (T2D) to reduce the risk of end-stage kidney disease and a sustained decrease in estimated glomerular filtration rate, as well as cardiovascular death, non-fatal myocardial infarction and hospitalization for heart failure. 

Finerenone Reduces New-Onset Atrial Fibrillation in Patients With Chronic Kidney Disease and Type 2 Diabetes  
Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at risk of atrial fibrillation or flutter (AFF) due to cardiac remodeling and kidney complications. Finerenone, a novel, selective, nonsteroidal mineralocorticoid receptor antagonist, inhibited cardiac remodeling in preclinical models. This study examines the effect of finerenone on new-onset AFF and cardiorenal effects by history of AFF in the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD) study. 

Cardiovascular Events with Finerenone in Kidney Disease and Type 2 Diabetes 
Among patients with type 2 diabetes and stage 2 to 4 CKD with moderately elevated albuminuria or stage 1 or 2 CKD with severely elevated albuminuria, finerenone therapy improved cardiovascular outcomes as compared with placebo.

Finerenone Reduces Risk of Incident Heart Failure in Patients With Chronic Kidney Disease and Type 2 Diabetes: Analyses From the FIGARO-DKD Trial
Chronic kidney disease and type 2 diabetes are independently associated with heart failure (HF), a leading cause of morbidity and mortality. In the FIDELIO-DKD (Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease) and FIGARO-DKD (Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease) trials, finerenone (a selective, nonsteroidal mineralocorticoid receptor antagonist) improved cardiovascular outcomes in patients with albuminuric chronic kidney disease and type 2 diabetes. 

NEJM: Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes (FIDELIO-DKD)

This report published in the New England Journal of Medicine details the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD) study, a phase 3, randomized, double-blind, placebo-controlled, multicenter clinical trial designed to test the hypothesis that finerenone slows CKD progression and reduces cardiovascular morbidity and mortality among patients with advanced CKD and type 2 diabetes.

Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease - FIGARO-DKD
The goal of the trial was to assess the safety and efficacy of finerenone in reducing cardiovascular (CV) events among patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). This report (updated in December 2021) published by the American College of Cardiology showed that finerenone has salutary effects on CV outcomes among patients with T2DM and CKD, who were on a background of maximal RAS blockade therapy, primarily due to a reduction in hospitalization for HF.

Drug Study Offers New Hope to Patients with Both Chronic Kidney Disease and Type 2 Diabetes
“Diabetes is the leading cause of kidney failure in the U.S. People with type 2 diabetes and CKD are also three times more likely to die of cardiovascular-related causes than those with type 2 diabetes alone,” said National Kidney Foundation’s Chief Scientific Officer Kerry Willis, PhD. “Having a new therapy that tackles both of these problems is a major advance and could potentially help millions of patients to lead longer, healthier lives.”

Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease
A series of preclinical studies revealed that MR is overactivated under diabetic conditions, resulting in promoting inflammatory and fibrotic process in the kidney. Recently, nonsteroidal MRAs, including finerenone, have been developed. These agents are highly selective and have potent anti-inflammatory and anti-fibrotic properties with a low risk of hyperkalemia. This 2021 study reviews the current knowledge and future perspectives of MRAs in DKD treatment.

Diagnosis and Management of Type 2 Diabetic Kidney Disease

This review provides an update on the diagnosis and management of DKD based on a comprehensive review of the medical literature. Topics addressed include the evolving presentation of DKD, clinical differentiation of DKD from non-DKD, a state-of-the-art evaluation of current treatment strategies, and promising emerging treatments. It is expected that the review will help clinicians to diagnose and manage patients with DKD.

Transplantation in the obese: separating myth from reality
In this review, the authors evaluate data about the safety of weight loss on dialysis and critically review the impact of pre-transplant body mass index and sarcopenia on post-transplant outcomes. They also highlight comparative data on outcomes of obese patients on dialysis versus those undergoing kidney transplantation.

Cardiovascular Complications of Diabetic Kidney Disease
Diabetic nephropathy is the most common cause of chronic kidney disease and represents a large and ominous public health problem. Patients with diabetic kidney disease have exceptionally high rates of cardiovascular morbidity and mortality. In fact, the excess mortality among patients with diabetes appears to be largely limited to the subgroup with kidney disease and explained by their high burden of cardiovascular disease.

Diabetic kidney disease: a report from an ADA Consensus Conference
The incidence and prevalence of diabetes mellitus have grown significantly throughout the world, due primarily to the increase in type 2 diabetes. This overall increase in the number of people with diabetes has had a major impact on development of diabetic kidney disease (DKD), one of the most frequent complications of both types of diabetes. DKD is the leading cause of end-stage renal disease (ESRD), accounting for approximately 50% of cases in the developed world.

Due to the high human and societal costs, the Consensus Conference on Chronic Kidney Disease and Diabetes was convened by the American Diabetes Association in collaboration with the American Society of Nephrology and the National Kidney Foundation to appraise issues regarding patient management, highlighting current practices and new directions.

KDIGO Clinical Practice Guideline for the Management of Glomerular Diseases
This set of resources from the Improving Global Outcomes (KDIGO) Glomerular Diseases Work Group will assist clinicians caring for individuals with glomerular disease, both adults and children. The scope includes various glomerular diseases, including IgA nephropathy (IgAN) and IgA vasculitis (IgAV), membranous nephropathy, nephrotic syndrome in children, minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), infection-related glomerulonephritis (GN), antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, lupus nephritis, and anti-glomerular basement membrane (anti-GBM) antibody GN. In addition, this guideline will be the first to address the subtype of complement-mediated diseases. 

Tangri, N., Peach, E.J., Franzén, S. et al. Patient Management and Clinical Outcomes Associated with a Recorded Diagnosis of Stage 3 Chronic Kidney Disease: The REVEAL-CKD Study, Adv Ther (2023)

CME Webinar: State-of-the-Art Treatment of DKD

To download a PDF of the presentation deck, click hereDepending on your browser settings, the file will either download or open in a new window.

When you have completed the webinar, click HERE to proceed to the post-presentation survey and your CE certificate.