Contributor: Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES
Did you know that 1 in 3 adults with diabetes also has kidney disease? It's true, diabetes is a risk factor for kidney disease. Other risk factors include high blood pressure, obesity, and family history. Particularly alarming is that the CDC estimates that 40% of people with severely reduced kidney function are not even aware they have chronic kidney disease (CKD). Having CKD puts you at a higher risk of cardiovascular disease. End-stage kidney disease requires dialysis and kidney transplant. Although these things sound scary, many ways exist to reduce our risks.
Screening for Kidney Disease
It’s recommended to check kidney function at least yearly, starting at diagnosis for those with type 2 diabetes and within five years of diagnosis for those with type 1 diabetes. Checking kidney function is done through a simple blood test which measures the amount of creatinine in the blood and provides an estimated glomerular function rate (eGFR), which states how well your kidneys are working to filter waste. Stage 3 CKD begins when eGFR is less than 60. A urine test can check for albuminuria or protein in the urine, which is a marker of damage to the kidney. A normal level is under 30. It’s important to screen using both tests, as one test can be normal while the other may be elevated.
Fortunately, many treatments are now available to keep the kidneys going strong. Most importantly, work to get blood pressure and glucose levels to goal if they are not already. Speak with your healthcare team about medications and lifestyle changes, such as reducing salt intake, increasing physical activity, and losing weight if overweight.
- ACE inhibitors and ARBs - These first-line treatments are also used to treat high blood pressure. ACE inhibitors and Angiotensin receptor blockers (ARBs) have been shown in many studies to protect the kidneys. An excellent way to remember ACE Inhibitors is that they all end in “pril.” For example, lisinopril and enalapril. ARBs all end in “sartan” such as losartan or valsartan. Most of these are taken once a day by mouth.
- SGLT2 inhibitors - These diabetes drugs have also shown benefits in protecting the kidneys. They all end in "flozin," like dapagliflozin, empagliflozin, and canagliflozin, and are all taken by mouth once daily. These drugs also decrease glucose levels and blood pressure. These drugs were previously avoided when kidney issues were present because they stopped being effective for glucose management. However, multiple large clinical trials have shown they are very effective at protecting the kidneys, even with low kidney function. The American Diabetes Association (ADA) recommends that these drugs specifically be used for anyone with kidney disease. They can be started at an eGFR as low as 20 and must only be stopped for dialysis. Also, drugs in this class have been studied in people with kidney disease but not diabetes and have shown benefits of preserving kidney function and decreasing the risk of cardiovascular events.
- Non-steroid mineralocorticoid antagonist - The newest drug class for kidney disease, the only medication currently in this class is finerenone. It has been studied when added to ACE inhibitors or ARBs and has benefits in preserving kidney function and decreasing cardiovascular events. This agent does not affect blood pressure or glucose levels. You can use it along with SGLT2 inhibitors for its kidney benefits. Of note, you should not use it if your eGFR is below 25. It is taken once a day by mouth.
- GLP-1 receptor agonists - These diabetes medications show some evidence that they may also protect the kidneys. This drug class is very effective at managing glucose and weight and reducing cardiovascular events. Since people with CKD have higher cardiovascular risk, these are a great option to add to SGLT2 inhibitors, especially if needed for glucose management. They can also be used instead of SGLT2 inhibitors if you experience side effects or have a low eGFR. Drugs in this class range from daily to weekly injectables and one daily oral option.
Thinking about kidney disease and the potential complications may sound scary. Fortunately, we now have many more treatment options than ever. Managing your blood pressure, weight, and glucose is the foundation, and now many medication options can also help.
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.