Remember: protect your kidneys, save your heart! Expert author @drkevinfernando. #MedTwitter #cardiotwitter #Nephpearls @goKDIGO pic.twitter.com/zoGZiU2NaK
— cardio-met (@cardiomet_CE) March 15, 2021
2) First, a poll. An eGFR <60ml/min means that your patient:
— cardio-met (@cardiomet_CE) March 16, 2021
(a) Is more likely to have ischaemic heart disease, HF, PVD, or cerebrovascular disease
(b) May be at increased risk of sustaining a hip fracture
(c) Is at increased risk of hypoglycaemia
(d) All of the above
2) First, a poll. An eGFR <60ml/min means that your patient:
— cardio-met (@cardiomet_CE) March 16, 2021
(a) Is more likely to have ischaemic heart disease, HF, PVD, or cerebrovascular disease
(b) May be at increased risk of sustaining a hip fracture
(c) Is at increased risk of hypoglycaemia
(d) All of the above
6) He has been living with T2D for 6 years and has background of CKD stage G3b A3 and is known to your renal colleagues. He also evidence of background diabetic retinopathy, hypertension and iron deficiency anaemia
— cardio-met (@cardiomet_CE) March 16, 2021
8) On examination home BP readings average 126/70, weight 77kg, no evidence fluid overload
— cardio-met (@cardiomet_CE) March 16, 2021
Bloods: eGFR 39ml/min, K 5, Ca 2.4 mmol/L (9.6 mg/dL), HbA1c 58mmol/mol (7.5%), Hb 121, Chol:HDL 7.4.
Urinary ACR 106 mg/mmol (938 mg/g)
So what do you do next?
continued
— cardio-met (@cardiomet_CE) March 16, 2021
10) Select your best answer and return tomorrow for results and more education! @EndoJournalClub @AHealthBlog @ypsendo @MedEdChat @MedEdBot @Mededucation101 @RpratleyMD @drricardocorrea @mvaduganathan @brendonneuen @vladoperkovic @AmarPut @kamleshkhunti @AbdTahrani @goKDIGO
— cardio-met (@cardiomet_CE) March 16, 2021
12) The updated KDIGO October 2020 guidelines (great reference document at https://t.co/m8W2VFEKXr) on diabetes management in CKD classify CKD based on GFR category (G1-G5) and albuminuria category (A1-A3). pic.twitter.com/GZZIU1l25G
— cardio-met (@cardiomet_CE) March 17, 2021
14) What about HbA1c targets in DKD? We know that tight glycaemic control reduces the risk of microvascular disease including DKD. However, there is no international consensus on glycaemic control in DKD.
— cardio-met (@cardiomet_CE) March 17, 2021
16) There is also potential harm from hypoglycaemia especially with insulin.
— cardio-met (@cardiomet_CE) March 17, 2021
In DKD HbA1c targets should be individualised to maintain a positive risk benefit ratio for the person in question. pic.twitter.com/EtdMAxbu5j
18) When using drugs to manage hyperglycaemia in DKD remember primum non nocere – first do no harm. Avoid adverse effects such as acute kidney injury (metformin used below eGFR 30ml/min) and hypoglycaemia (both sulphonylureas and insulins)
— cardio-met (@cardiomet_CE) March 17, 2021
20) the “SADMAN” mnemonic – stop SGLT2 inhibitors, ACEI, Diuretics, Metformin, ARB & NSAIDs during acute dehydrating illness and restart once eating and drinking normally after 24-48 hours
— cardio-met (@cardiomet_CE) March 17, 2021
22) Please return tomorrow for more education about the management of DKD in a primary care practice. I am @drkevinfernando. Shout outs to @idasgupta7 @drpatrickholmes @AmarPut @kamleshkhunti @AbdTahrani
— cardio-met (@cardiomet_CE) March 17, 2021
24) How do we delay the progression of DKD?
— cardio-met (@cardiomet_CE) March 18, 2021
The @goKDIGO guidelines suggested all with diabetes and CKD be treated with a comprehensive strategy to reduce risks of kidney disease progression and CVD pic.twitter.com/hSg1YWGXN3
26) . . . Advise on smoking cessation as appropriate.
— cardio-met (@cardiomet_CE) March 18, 2021
NICE CG181 (2014) guidance suggests statins (specifically atorvastatin 20mg) for primary and secondary prevention of CVD if eGFR <60ml/min
28) Anti-platelet therapy in CKD/DKD remains contentious. Benefits for the secondary prevention of CVD are irrefutable but expert opinion varies for primary prevention. The ASCEND trial (NEJM 2018) demonstrated no net benefit for ASA for primary prevention of CVD in diabetes.
— cardio-met (@cardiomet_CE) March 18, 2021
30) . . . which demonstrated significant reductions in major adverse renal outcomes. Notably DAPA-CKD also demonstrated this in a population of individuals with CKD but WITHOUT diabetes.
— cardio-met (@cardiomet_CE) March 18, 2021
DAPA-CKD: N Engl J Med 2020; 383:1436-1446
CREDENCE: N Engl J Med 2019; 380:2295-2306
32) pic.twitter.com/yzLp6G2HHN
— cardio-met (@cardiomet_CE) March 18, 2021
34) . . . then an SGLT2 inhibitor with evidence for reducing CKD progression should be preferentially used. Currently this includes both dapagliflozin and canagliflozin
— cardio-met (@cardiomet_CE) March 18, 2021
36) Now regarding our case study, it is reasonable to add in dapagliflozin 10mg od or canagliflozin 100mg od and alert my renal colleagues of his declining eGFR – 20% drop over 12 months and a resultant drop in GFR category to stage G3b.
— cardio-met (@cardiomet_CE) March 18, 2021
37) That's it! You made it! Free CE/#CME! Now go to https://t.co/o3hD2KrPEA and claim your credit–physicians, nurses, pharmacists! I am @drkevinfernando. Follow @cardiomet_CE for more tweetorials! #medtwittter #cardiotwitter @MedTweetorials
— cardio-met (@cardiomet_CE) March 18, 2021