Addressing cardiorenal outcomes in CKD and T2D: What are the key considerations for daily practice?

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    Faculty & Disclosures
    Prof. Peter Rossing

    Steno Diabetes Center Copenhagen, Herlev, Denmark

    Prof. Peter Rossing is head of complications research and chief physician at the Steno Diabetes Center Copenhagen, and professor in endocrinology with a focus on diabetic angiopathy at the University of Copenhagen. He leads a team dedicated to the research of micro-and macrovascular complications of diabetes and, since obtaining a specialist degree in internal medicine and endocrinology in 2004, has investigated the pathophysiology of the diabetic kidney at different stages, identifying several key risk markers for the development of diabetic nephropathy. read more

    He has been involved in several intervention studies in patients with overt diabetic nephropathy aiming at improving prognosis. In addition to studies on conventional antihypertensive agents, he has also been involved in some of the first studies of angiotensin II receptor blockers, aldosterone antagonists and, most recently, studies of direct renin inhibition with aliskiren in diabetic kidney disease.

    Prof. Rossing has co-authored over 570 publications and has an h–index of 79. He has received several national and international awards, including The Minkowski Prize from the European Association for the Study of Diabetes (EASD) in 2005, the Ruth Østerby Award from the European Diabetic Nephropathy Study Group in 2013, the EASD Camillo Golgi Prize in 2016, and the European Hormone Medal from the European Society of Endocrinology in 2022.

    Prof. Peter Rossing discloses: Consultancy fees from Astellas, AstraZeneca, Bayer, Boehringer Ingelheim (BI), Eli Lilly and Company, Gilead, Merck Sharp and Dohme (MSD), Novo Nordisk and Sanofi. Grants/research support from AstraZeneca, Bayer and Novo Nordisk.
    Dr Eden Miller

    Diabetes and Obesity Care, Bend, Oregon, USA

    Dr Eden Miller, an Osteopathic Board-certified family practitioner, received her medical degree from Kirksville College of Osteopathic Medicine in 1997. She completed her residency in family practice at Eastmoreland Hospital in Portland, Oregon and recently completed her certification in obesity management. She is the founder of Diabetes Nation, a nonprofit organization, and CEO of Diabetes and Obesity Care in Bend, Oregon, where she currently practices. read more

    Dr Miller cultivated a special interest in diabetes after contracting type 1 diabetes while in medical school and, from that personal experience, her practice has extended to subspecialize in diabetes care.

    An impassioned speaker, Dr Miller has given more than 1,250 lectures in the field of diabetes to healthcare professionals and patients alike, on subjects such as diabetes management, continuous glucose monitoring technology, insulin pump therapy, obesity and metabolism intervention, clinical research, and healthcare policy. Her adage for care is that “I only succeed as a provider if I turn patients into experts on their own disease.”

    Dr Miller believes that a physiologic, patient-individualized approach to diabetes intervention is crucial to success and that there needs to be a “collaborative effort” where patients are “unhindered by fear of personal scrutiny” and that “barriers for effective treatment need to be removed.”

    Dr Eden Miller discloses: Advisory board/panel fees from Abbott, Bayer, Eli Lilly and Company, and Novo Nordisk. Grants/research support from Abbott. Speaker’s bureau fees from Abbott, Bayer, Boehringer Ingelheim (BI), Eli Lilly and Company, and Novo Nordisk.
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    Progression of CKD: What are the epidemiological and pathophysiological drivers?
    What are the cardiorenal risks associated with CKD and T2D and how can they be addressed?
    How can the latest clinical guidelines for treating CKD and T2D be applied in daily practice?
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    A relaxed discussion between two faculty focussed on real world clinical issues. Useful tips below will show how to navigate the activity. Join the conversation. Close

    Addressing cardiorenal outcomes in CKD and T2D: What are the key considerations for daily practice?

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    Learning Objectives

    After watching this activity, participants should be better able to:

    • Identify the epidemiological and pathophysiological drivers behind the progression of CKD
    • Recognize the specific renal and cardiovascular risks associated with CKD and T2D and the therapies available to address them
    • Apply the latest clinical guidelines to treating patients with CKD and T2D in daily practice
    Overview

    In this activity, an expert in endocrinology and an expert in primary care respond to questions from the CKD and T2D community on monitoring CKD progression, reducing the risk of cardiorenal outcomes, and applying the latest guidelines on CKD and T2D to daily practice.

    This activity is jointly provided by USF Health and touchIME. read more

    Target Audience

    This activity has been designed to meet the educational needs of nephrologists, primary care physicians, endocrinologists and cardiologists involved in the management of chronic kidney disease in type 2 diabetes.

    Disclosures

    USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

    Faculty

    Prof. Peter Rossing discloses: Consultancy fees from Astellas, AstraZeneca, Bayer, Boehringer Ingelheim (BI), Eli Lilly and Company, Gilead, Merck Sharp and Dohme (MSD), Novo Nordisk and Sanofi. Grants/research support from AstraZeneca, Bayer and Novo Nordisk.

    Dr Eden Miller discloses: Advisory board/panel fees from Abbott, Bayer, Eli Lilly and Company, and Novo Nordisk. Grants/research support from Abbott. Speaker’s bureau fees from Abbott, Bayer, Boehringer Ingelheim (BI), Eli Lilly and Company, and Novo Nordisk.

    Content reviewer

    Claude Bassil, MD, FACP, FASN has no financial interests/relationships or affiliations in relation to this activity.

    Touch Medical Director

    Sola Neunie has no financial interests/relationships or affiliations in relation to this activity.

    USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

    Requirements for Successful Completion

    In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

    If you have questions regarding credit please contact cpdsupport@usf.edu

    Accreditations

    Physicians

    This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

    USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu)

    Advanced Practice Providers

    Physician Assistants may claim a maximum of 0.75 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTMfrom organizations accredited by ACCME or a recognized state medical society.

    The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

    Date of original release: 25 October 2022. Date credits expire: 25 October 2023.

    If you have any questions regarding credit please contact cpdsupport@usf.edu

    This activity is CE/CME accredited

    To obtain the CE/CME credit(s) from this activity, please complete this post-activity test.

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    Cardiovascular Disease / Heart Failure / Stroke
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    This Activity Is Funded By:

    An independent medical education grant from Bayer.
    This activity is jointly provided by USF Health and touchIME.

    The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

    USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

    USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

    Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

    This content is intended for healthcare professionals.

    Date of original release: 25 October 2022. Date credits expire: 25 October 2023.

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    Addressing cardiorenal outcomes in CKD and T2D: What are the key considerations for daily practice?
    0.75 CE/CME credit
    Question 1/5
    You have a 65-year-old male patient who has T2D and CKD. He is overweight with an eGFR of 57 mL/min/1.73 m2 and his UACR is 290 mg/g. How would you determine his prognosis of CKD?

    CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HbA1c, glycated haemoglobin; KDIGO, Kidney Disease: Improving Global Outcomes; LDL-C, low-density lipoprotein cholesterol; T2D, type 2 diabetes; UACR, urine albumin-creatinine ratio.

    KDIGO recommends classifying CKD based on cause (C), GFR category (G) and albuminuria (A); known as the CGA classification. The KDIGO ‘heat map’ represents the prognosis of CKD according to six GFR (G1–G5) and three persistent albuminuria categories (A1–A3). A GFR ≥90 mL/min/1.73 m2 is considered normal to high, while a GFR <15 indicates kidney failure. Albuminuria levels of <30 mg/g are considered normal to mildly increased, while albuminuria levels >300 mg/g are considered severely increased. By combining the various GFR and albuminuria categories, the prognosis of CKD can be determined, where green is low risk (if no other markers of kidney disease, no CKD), yellow is moderately increased risk, orange is high risk, and red is very-high risk.

    Abbreviations

    CKD, chronic kidney disease; GFR, glomerular filtration rate; KDIGO, Kidney Disease: Improving Global Outcomes.

    Reference

    Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. Kidney Int. 2020;98(Suppl.):S1–115.

    Question 2/5
    Which of the following cardiorenal outcomes are associated with CKD and T2D?

    CKD, chronic kidney disease; T2D, type 2 diabetes.

    The association between T2D and CKD is well-defined, with multimorbidity resulting in considerable disease burden and reduced quality of life for patients. In a population-based cohort studying 473,399 patients with T2D, the lifetime risk of MARCE (defined as cardiovascular death and cardiovascular renal diseases: heart failure, myocardial infarction, stroke, or peripheral artery disease) was estimated. The risk of MARCE for patients with CKD was 93%, and for those without cardiovascular and renal disease, it was 80%.

    Abbreviations

    CKD, chronic kidney disease; MARCE, major adverse renal and cardiovascular events; T2D, type 2 diabetes.

    Reference

    Zhang R, et al. BMC Med. 2022;20:63.

    Question 3/5
    You have a 54-year-old male patient with T2D and progressive CKD. He has been taking benazepril, nifedipine, metformin and glipizide for the past 5 years. For the past year, he has also been taking dapagliflozin. However, despite this treatment he is still exhibiting albuminuria (UACR 360 mg/g). His eGFR is 45 mL/min/1.73 m2 and he has good glycaemic control. What treatment plan would you consider next for your patient?

    ACE, angiotensin-converting enzyme; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide 1 receptor agonist; MRA, mineralocorticoid receptor antagonist; T2D, type 2 diabetes; UACR, urine albumin-creatinine ratio.

    There is evidence to suggest combination therapy with SGLT2 inhibitors and finerenone, a non-steroidal MRA, may reduce cardiorenal risk more effectively than either alone.1 Both agents protect kidney function through distinct yet complementary pathways, which exert their beneficial effects independently.1 Combination therapy may also decrease the risk of hyperkalaemia, a recognized complication of finerenone therapy.2

    GLP-1 RAs are a class of anti-hyperglycaemic drugs that offer adequate glycaemic control in patients with T2D and CKD, without the increased risk of hypoglycaemia.3 KDIGO recommends GLP-1 RAs in those not achieving their individualized glycaemic targets with metformin plus an SGLT2 inhibitor, or those unable to use an SGLT2 inhibitor. KDIGO also recommends discontinuing metformin once eGFR is <30 mL/min/1.73 m2.4

    Abbreviations

    CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide 1 receptor agonist; KDIGO, Kidney Disease: Improving Global Outcomes; MRA, mineralocorticoid receptor antagonist; SGLT2, sodium–glucose co-transporter 2; T2D, type 2 diabetes.

    References

    1. Neuen BL, Jardine MJ. Nephrol Dial Transplant. 2022;37:1209–11.
    2. Neuen BL, et al. Eur Heart J. 2021;42;4891–901.
    3. Górriz JL, et al. J Clin Med. 2020;30:947.
    4. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. Kidney Int. 2020;98:(Suppl.):S1–115.
    Question 4/5
    Your 58-year-old female patient is being treated for CKD and T2D with metformin and dapagliflozin. Recent blood results suggest that your patient is not achieving her individualized HbA1c target (7.2%). Considering the KDIGO 2020 guidelines, what add-on treatment would you initiate next for your patient?

    CKD, chronic kidney disease; HbA1c, glycated haemoglobin; KDIGO, Kidney Disease: Improving Global Outcomes; T2D, type 2 diabetes.

    KDIGO 2020 guidelines recommend the use of a long-acting GLP-1 RA in patients with T2D and CKD who have not achieved their individualized glycaemic targets despite use of metformin and an SGLT2 inhibitor.1 The chosen GLP-1 RA should have documented cardiovascular benefits.1 In the REWIND trial (N=9,901), the long-acting GLP-1 RA dulaglutide was superior to placebo in reducing non-fatal myocardial infarction, non-fatal stroke and death from cardiovascular causes or unknown causes (HR 0.88; p=0.026).2 Lixisenatide is a short-acting GLP-1 RA,3 and did not significantly alter the rate of cardiovascular death, myocardial infarction, stroke, or hospitalization for unstable angina (HR 1.02; p=0.81) in the ELIXA trial (N=6,068).4

    Abbreviations

    CKD, chronic kidney disease; GLP-1 RA, glucagon-like peptide 1 receptor agonist; HR, hazard ratio; KDIGO, Kidney Disease: Improving Global Outcomes; SGLT2; sodium–glucose co-transporter 2; T2D, type 2 diabetes.

    References

    1. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. Kidney Int. 2020;98:(Suppl.):S1–115.
    2. Gerstein HC, et al. Lancet. 2019;394:121–30.
    3. Nauck MA, et al. Mol Metab. 2021;46:101102.
    4. Pfeffer MA, et al. N Engl J Med. 2015;373:2247–57.
    Question 5/5
    You have a 61-year-old female patient who has T2D, stage 3 CKD, with albuminuria (UACR 180 mg/g) and an eGFR of 43 mL/min/1.73 m2. She has a history of recurrent complicated urinary tract infections; therefore, to mitigate any potential side effects of an SGLT2 inhibitor, you suggest treatment with a non-steroidal MRA. To further assess her suitability for this treatment, what would you do?

    CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; MRA, mineralocorticoid receptor antagonist; SGLT2, sodium–glucose co-transporter 2; T2D, type 2 diabetes; UACR, urine albumin-creatinine ratio.

    Due to its mechanism of action, finerenone is associated with an increased risk of hyperkalaemia.1 Therefore, before treatment initiation, serum potassium should be measured to determine if finerenone treatment is suitable. If serum potassium is >5.0 mmol/L, finerenone treatment should not be initiated. If the candidate is suitable, monitoring of serum potassium is recommended in all patients 4 weeks after initiation of finerenone and periodically thereafter as needed, based on the patient’s individual characteristics.2

    References

    1. Agarwal R, et al. Eur Heart J. 2022;43:474–84.
    2. Finerenone SmPC. Available at: https://bit.ly/3s1c9Ig (accessed 14 October 2022).
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    This Activity Is Funded By:

    An independent medical education grant from Bayer.
    This activity is jointly provided by USF Health and touchIME.

    The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

    USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

    USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

    Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

    This content is intended for healthcare professionals.

    Date of original release: 25 October 2022. Date credits expire: 25 October 2023.

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