Controlling Chronic Kidney Disease in Type 2 Diabetes

Jennifer B. Green, MD: We talked a little about ways to reduce the risk of specific complications. We should take a moment to talk about some of the advances in the care of patients with diabetes and chronic kidney disease. Would you mind taking a moment to talk about how the care of such patients has expanded dramatically in recent years, particularly with the wrap-up of the key finerenone trials? We’re entering a new space for the care of such patients that will hopefully change their traditional trajectory of kidney failure.

Dennis Bruemmer, MD, PhD: One of the main problems with microvascular complications in patients with diabetes is that for a long time there was no treatment other than ACE inhibitors and ARBs [angiotensin-receptor blockers], which are well established in patients with microalbuminuria in type 1 and type 2 diabetes. We’ve entered an era where we have medications to prevent kidney complications very effectively in patients with diabetes. Obviously, we have the SGLT2 inhibitors, which are well established through the CREDENCE and DAPA-CKD trials. DAPA-CKD extended this benefit from patients with diabetes to patients without diabetes. Then we have newer agents, like finerenone, which falls into the mineralocorticoid antagonist group. The idea came out of early spironolactone data, which had shown less progression in albuminuria in patients with type 2 diabetes. We went on to finerenone, and now the FIDELIO-DKD trial had been completed, which included about 5000 patients with type 2 diabetes and an increased albumin-to-creatinine ratio and retinopathy, whereas the second arm in the study had higher levels of the albumin-to-creatinine ratio.

In this study, the primary outcome was a composite of kidney failure decrease in the GFR [glomerular filtration rate] to less than 40 mL/min from baseline over a period. It also included death from renal causes. There was a significant reduction in the primary end point, 17.8% primary end point occurrence in the group with finerenone vs 21% with placebo. That’s a protective effect. This extends our armamentarium of all the data we’re looking at with SGLT2 inhibitors or mineralocorticoid receptor antagonists on top of the ACE and ARBs. We extended the armamentarium from ACE and ARBs to SGLT2 inhibitors and now to mineralocorticoid receptor antagonists. One important question is, what happens when we combine these optimal ACEs and ARBs plus an SGLT2 inhibitor plus a mineralocorticoid receptor antagonist, such as finerenone? What will we see? How much of morbidity and renal-related mortality can we reduce with these novel agents? But these are very promising new approaches, and it’s a very exciting area to be in the care for diabetes with all the all the new developments.

Jennifer B. Green, MD: It’s an exciting time. Before we move on, I want to mention that there are nonpharmacological options that convey outcome benefits as well. I’m guilty of probably not referring my patients to at least consider the option of bariatric surgery as often or as early as I should in the course of their disease. When we think about the outcomes data that we’ve seen in the bariatric surgery studies, they often aren’t randomized trials, but they’re very well conducted and complete studies—many of which were conducted in Sweden, which has very robust health care data for all its citizens. It’s very clear that the earlier patients with diabetes and obesity undergo bariatric surgery as clinically appropriate, the more likely they are to experience a remission in diabetes, at least in the short term after surgery, and the greater the reduction in their risk of both microvascular and macrovascular complications. It doesn’t always have to be something we achieve through use of medications.

Of course, weight loss is a very important intervention. The type of weight loss we see with bariatric surgery has very meaningful benefits in our patient population. But if we wait too long, those benefits are minimized to some extent, so I’m personally trying to not wait until all other options to improve a person’s health are exhausted before I consider the option of bariatric surgery. That has perhaps been the traditional way that bariatric surgery is considered—as a last resort—when we need to be thinking about it very early on in the course of disease.

Thank you, Dr Bruemmer. And I’d like to thank everyone for watching this HCPLive® Peers & Perspectives®. If you enjoyed the content, please subscribe to the e-newsletters to receive upcoming Peers & Perspectives® and other great content right in your in-box. Thank you very much.

Transcript edited for clarity.