ESC Chronic kidney disease & Diabetes.pptx

1. 2023 ESC Guidelines for the management of
cardiovascular disease in patients with diabetes
Will Herrington, University of Oxford
August 26th, 2023
Chronic kidney disease
(CKD) and diabetes

2. ©ESC
www.escardio.org/guidelines

3. ©ESC
Central figure
Management of CV
disease in patients
with type 2 diabetes:
clinical approach &
key recommendations
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines

4. ©ESC
2019 2023
Key changes to CKD and diabetes recommendations 2019-2023
SGLT2i – even clearer evidence of efficacy, even at low GFR
Finerenone=a new treatment option in patients with albuminuria
Emphasis on glucose-lowering agents which reduce risk
Key message: start treatments early (don‘t wait for nephrologists)!
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines

5. ©ESC
KDIGO CKD staging and risk of kidney replacement therapy
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines
Recommendations Class Level
It is recommended that patients with diabetes are routinely screened for kidney
disease by assessing eGFR defined by CKD-EPI and UACR.
I B

6. ©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Kidney International 2011 8017-28
www.escardio.org/guidelines
Cardiovascular risk in patients with diabetes and CKD
Kidney failure (ESRD) Cardiovascular mortality All-cause mortality
ACR
<10
ACR
10–29
ACR
30–299
ACR
≥300
eGFR
>105
Ref Ref 7.8 18
eGFR
90–105
Ref Ref 11 20
eGFR
75–90
Ref Ref 3.8 48
eGFR
60–75
Ref Ref 7.4 67
eGFR
45–60
5.2 22 40 147
eGFR
30–45
56 74 294 763
eGFR
15–30
433 1044 1056 2286
ACR
<10
ACR
10–29
ACR
30–299
ACR
≥300
eGFR
>105
0.9 1.3 2.3 2.1
eGFR
90–105
Ref 1.5 1.7 3.7
eGFR
75–90
1.0 1.3 1.6 3.7
eGFR
60–75
1.1 1.4 2.0 4.1
eGFR
45–60
1.5 2.2 2.8 4.3
eGFR
30–45
2.2 2.7 3.4 5.2
eGFR
15–30
14 7.9 4.8 8.1
ACR
<10
ACR
10–29
ACR
30–299
ACR
≥300
eGFR
>105
1.1 1.5 2.2 5.0
eGFR
90–105
Ref 1.4 1.5 3.1
eGFR
75–90
1.0 1.3 1.7 2.3
eGFR
60–75
1.0 1.4 1.8 2.7
eGFR
45–60
1.3 1.7 2.2 3.6
eGFR
30–45
1.9 2.3 3.3 4.9
eGFR
15–30
5.3 3.6 4.7 6.6

7. ©ESC
Pharmacological management to reduce cardiovascular or kidney failure
risk in patients with type 2 diabetes and chronic kidney disease
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines

8. ©ESC
LDL-cholesterol in CKD and diabetes
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
LDE 2016; 4: 829-39
www.escardio.org/guidelines
Recommendation Class Level
Intensive LDL-C lowering with statins or a statin/ezetimibe combination is
recommended.
I A
CTT

9. www.escardio.org/guidelines
©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
BP & RAS inhibitors in CKD and diabetes
1. NEJM 2001; 345:870-878
2. NEJM 2001; 345:851-860
3. NEJM 2001; 345:861-869
Recommendations Class Level
A BP target of ≤130/80 mmHg is recommended to reduce risk of CVD and
albuminuria.
I A
The maximum tolerated dose of an ACE-I or ARB is recommended. I A
IRMA21 IDNT2 RENAAL3

10. www.escardio.org/guidelines
©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
No “Dual blockade” in CKD and diabetes
NEJM 2013; 369: 1892-903
Recommendation Class Level
Combined use of an ARB with an ACE-I is NOT recommended. III B
VA NEPHRON-D

11. 1.
2.
3.
NEJM 2019; 380:2295-306
NEJM 2020; 383:1436-46
NEJM 2023; 388:117-27
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines
©ESC
SGLT2 inhibitors in CKD and diabetes
Recommendation Class Level
An SGLT2 inhibitor (canagliflozin, empagliflozin, or dapagliflozin) is recommended in
patients with T2DM and CKD with an eGFR ≥20 mL/min/1.73 m2 to reduce the risk of
CVD and kidney failure.
I A
CREDENCE1 DAPA-CKD2 EMPA-KIDNEY3

12. ©ESC
Finerenone in CKD and diabetes
FIDELIO-DKD1 FIGARO-DKD2
CV primary outcome
Kidney disease progression primary outcome
Recommendation
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
1. NEJM 2020; 383:2219-2229
2. NEJM 2021; 385:2252-2263
www.escardio.org/guidelines
Class Level
Finerenone is recommended in addition to an ACE-I or ARB in patients with T2DM
and eGFR >60 mL/min/1.73 m2 with a UACR ≥30 mg/mmol (≥300 mg/g), or
eGFR 25–60 mL/min/1.73 m2 and UACR ≥3 mg/mmol (≥30 mg/g) to reduce CV events
and kidney failure.
I A

13. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines
©ESC
Glucose control in CKD and diabetes
Recommendation Class Level
Personalized HbA1c targets 6.5–8.0% (48–64 mmol/mol) are recommended, with a
target <7.0% (<53 mmol/mol) to reduce microvascular complications, wherever
possible.
I A
A GLP-1 RA is recommended at eGFR >15 to achieve adequate glycaemic control, due
to low risk of hypoglycaemia and beneficial effects on weight, CV risk, and
albuminuria.
I A

14. ©ESC
Pharmacological management to reduce cardiovascular or kidney failure
risk in patients with type 2 diabetes and chronic kidney disease
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines

15. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines
©ESC
When to involve a nephrologist?
Recommendations Class Level
Kidney specialist advice may be considered for managing a raised serum phosphate,
other evidence of CKD-MBD, and renal anaemia.
IIb C

16. ©ESC
When to involve a nephrologist?
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines
Recommendations Class Level
Kidney specialist advice may be considered for managing a raised serum phosphate,
other evidence of CKD-MBD, and renal anaemia.
IIb C

17. ©ESC
Thank you for caring for the heart and the kidneys!
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
www.escardio.org/guidelines