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Renal Risk in Type 2 Diabetes
Reducing Renal Risk in Patients with Type 2 Diabetes

Released: November 26, 2024

Expiration: November 25, 2025

Jennifer B Green
Jennifer B Green, MD
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Key Takeaways
  • The overlapping pathophysiologies of T2D, CKD, and CVD often cause patients to develop more than one of these conditions.
  • GLP-1 receptor agonists and SGLT2 inhibitors can be used to mitigate the risks associated with CVD, CKD, and T2D.

In this commentary, an endocrinology expert answers questions that were asked during a live event on navigating recent clinical evidence for renal risk reduction in patients with type 2 diabetes (T2D) as well as the efficacy of glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter-2 (SGLT2) inhibitors in the treatment of T2D and chronic kidney disease (CKD). The importance of patient education for improving outcomes is also discussed.

How does BMI affect your decision regarding GLP-1 receptor agonist treatment?
The use of GLP-1 receptor agonists to reduce cardiorenal risk is not dependent on BMI. GLP-1 receptor agonists are beneficial even when weight loss is not the main goal. Moreover, although overweight and obesity are defined by BMI, it may not accurately reflect the health status of all patients. If these agents are prescribed specifically for weight loss, it is important to determine whether patients might have overweight or obesity even though their BMI does not meet standard cutoffs. For example, BMI thresholds for overweight and obesity are lower in individuals from Asia. With respect to cardiorenal risk reduction, BMI does not need to be considered when determining whether patients will benefit from GLP-1 receptor agonists. In fact, there was no BMI cutoff for enrollment in the FLOW study in which the effects of GLP-1 receptor analogues on cardiovascular and kidney outcomes were investigated in persons with kidney impairment and T2D. However, in SELECT, a trial of patients with overweight or obesity (according to BMI cutoff) and established atherosclerotic cardiovascular disease (CVD) but not diabetes, showed that semaglutide reduced the risk of major adverse cardiovascular events.  If excess weight is specifically being addressed, the considerations are different.  

When do you consider using SGLT2 inhibitors in patients with T2D? 
I would consider SGLT2 inhibitors for the management of hyperglycemia in all patients with T2D. These agents are definitely indicated for patients who are at high risk of atherosclerotic cardiovascular disease events and those with heart failure. Moreover, SGLT2 inhibitors are really a foundational therapy for patients with T2D and CKD. In fact, some may even argue that although these agents mainly serve as kidney or cardiovascular drugs, they have a glucose-lowering effect and would therefore be beneficial for most patients with T2D.

Would you use a GLP-1 receptor agonist in a patient with CKD but without T2D?
In such a patient, an SGLT2 inhibitor would be indicated, in addition to an ACE inhibitor or angiotensin II receptor blocker. If the patient has obesity, a GLP-1 receptor agonist may be used for that reason, but the FLOW data with semaglutide are specific to patients with T2D and CKD. Unfortunately, up to 75% of patients with CKD are not being started on these agents, exposing them to an increased risk of CV events and kidney disease progression.

How often do you educate patients with T2D and CKD about their conditions?
The American Diabetes Association (ADA) emphasizes the importance of access to annual nutritional and diabetes education for all patients with diabetes, including those with long-standing diabetes and CKD. How this education is delivered can vary and may even involve telemedicine visits, but it is important that patients receive this type of education. Over 38 million people in the US have diabetes—that is nearly 1 in every 10 adults. However, 1 in 5 are not aware they have it, and more than 1 in 3 adults have prediabetes, with more than 8 in 10 being unaware of that condition. To overcome this barrier, patients need to be educated about their condition and the benefits of lifestyle modification and medications currently available to optimize their health.

Your Thoughts?
How often do you consider CKD when prescribing therapy for T2D?  Get involved in the discussion by answering the polling question and posting a comment below.

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How often do you consider concurrent CKD when prescribing therapy for T2D?

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