Diabetes and Kidney Disease

A Healthier You

Diabetes and Kidney Disease

Diana IsaacsContributor: Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES

It’s not fun to think about, but having diabetes puts you at greater risk of kidney problems. In fact, diabetes is the most common cause of chronic kidney disease (CKD). Approximately 30% of people with type 1 diabetes and 40% of those with type 2 diabetes have CKD.

The kidneys have several important jobs in the body. They maintain blood pressure, remove waste, make red blood cells, keep bones healthy, and regulate salt and acid balance. Having kidney disease and diabetes increases the risk of cardiovascular events like heart failure, heart attacks, strokes, and even death.

How Do You Know if You Have Kidney Disease?
While this may sound scary, there have been tons of advances in treatments for kidney disease. The first step is to find out if you have it. Data from the Centers for Disease Control and Prevention shows that 48% of people with severely reduced kidney function were unaware that they had kidney disease! The American Diabetes Association (ADA) recommends screening at diagnosis of type 2 diabetes and after five years of having type 1 diabetes. Screening is done by checking a blood test for serum creatinine level and the estimated glomerular filtration rate (eGFR). A urine test is performed to check for albumin in the urine, also called albuminuria, through a test called UACR, a urinary albumin-to-creatinine ratio. At least two positive tests are needed over 3 to 6 months to make a diagnosis. When eGFR is under 60ml/min/1.73m2 or the UACR is over 30 mg/g, this indicates chronic kidney disease. The lower the eGFR and greater the amount of albuminuria indicate more severe kidney disease.

What You Can Do For Your Kidneys
Fortunately, there are several things you can do to help your kidneys. Managing blood sugar and blood pressure levels is vital to protect your kidneys. Several lifestyle factors like physical activity and maintaining a healthy weight can also protect your kidneys. If you have high blood pressure, it is recommended you take an ACE inhibitor or angiotensin receptor blocker (ARB).

SGLT2 Inhibitors
In recent years, several new medications have been found to help the kidneys. Specifically, the sodium-glucose co-transporter 2 (SGLT2) inhibitors have shown significant effects on protecting the kidneys in multiple randomized, controlled trials - the highest level of evidence. These drugs cause more glucose to be released in the urine, leading to a loss of calories (weight loss) and lower blood sugar. They also lower blood pressure. Two of the drugs in this class have a special indication for the kidneys. Canagliflozin (Invokana) is FDA approved to reduce the risk of end-stage kidney disease, doubling of serum creatinine, cardiovascular death, and hospitalization for heart failure in adults with type 2 diabetes and albuminuria greater than 300mg/day. Another drug in this class, dapagliflozin (Farxiga), is FDA approved to reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, and hospitalization for heart failure in adults with CKD. Dapagliflozin is approved for people with CKD even if they do not have diabetes. Another drug in the class, empagliflozin (Jardiance), does not have a specific indication but has shown benefits to the kidneys in clinical trials. The ADA recommends SGLT2 inhibitors for people with cardiovascular disease, heart failure, or kidney disease, even if A1C is at goal because of their benefits on the heart and kidneys.

GLP-1 Receptor Agonists
Another class of medications preferred for people with diabetes and cardiovascular disease or kidney disease is the glucagon-like-peptide-1 receptor agonists. (GLP-1 RA). This drug class does not have a specific indication for kidney disease, but multiple studies support benefits for the kidneys. They also have many other benefits, including weight loss and blood sugar lowering. Several drugs in the class have a specific cardiovascular indication since they reduce heart attacks, strokes, and death. Neither the GLP1 agonists nor SGLT2 inhibitors cause hypoglycemia, although there can be an increased risk if they are combined with insulin.

The Newest Drug on the Block
The newest drug approved for diabetes and kidney disease is finerenone (Kerendia). It’s a new class of medication called a nonsteroid mineralcorticoid receptor antagonist. In people with kidney disease, there is minercortocioid receptor overexpression which causes more damage. Finerenone is indicated to reduce the risk of sustained eGFR decline, end-stage kidney disease, cardiovascular death, and heart attacks in adults with CKD associated with type 2 diabetes. The ADA recommends finerenone in people with CKD who are at increased risk for cardiovascular events or CKD progression or are unable to use an SGLT2 inhibitor.

A Message of Hope
You may be reading this and have end-stage kidney disease or know someone that does. When people get to end-stage, they usually go on dialysis and may not be able to use some of the drugs mentioned above. Many will go on the transplant list. I am fortunate to work with people after they get kidney transplants. I get to see so many people thrive after getting a new kidney! While no one wants to plan for this (as there is no guarantee you will find a match and you'll need lifelong immunosuppressive therapy), it's nice to know there are options out there. And we continue to learn new information about how the medications mentioned above can help protect a kidney after a transplant.

The Bottom Line
There are multiple options for people with diabetes and kidney disease. Everyone can reduce their risk by managing blood pressure and blood sugar and incorporating healthy lifestyle changes like balanced eating and regular physical activity. An important step is to find out if you have kidney disease. Ask your healthcare team to test you if you’re unsure, and ask them to explain the results if you have recently been tested. If you have kidney disease and high blood pressure, ask about taking an ACEI inhibitor or ARB. For managing your blood sugars, ask about taking an SGLT2 inhibitor and/or GLP1 agonist. In addition, ask your healthcare team if you may be a candidate for finerenone. We now have more treatment options than ever to protect you and your kidneys.

Diana Isaacs, PharmD, BCPS, BC-ADM, BCACP, CDCES is a Clinical Pharmacist and CGM Program Coordinator at the Cleveland Clinic Diabetes Center. Dr. Isaacs earned her Bachelor’s Degree in Chemistry from the University of Illinois at Chicago ans Doctor of Pharmacy Degree from Southern Illinois University Edwardsville. Dr. Isaacs holds board certifications in pharmacotherapy, ambulatory care, and advanced diabetes management. She is the Communications Director for the American Diabetes Association (ADA) Pregnancy and Reproductive Health Interest Group and serves on the 2020-2021 ADA Professional Practice Committee, the committee that updates the ADA Standards of Care. She presents on diabetes related topics nationally and internationally. Dr. Isaacs was awarded the Ohio Pharmacists Association Under 40 Award in 2019 and ADCES Diabetes Care and Education Specialist of the Year in 2020.