Case based on the cJASN article: https://cjasn.asnjournals.org/content/16/10/1578

1. HOW TO OPTIMIZE
THE MANAGEMENT
OF CKD PATIENT
Mohamed E. Elrggal

2. Case Scenario
42-year-old woman C/O: progressive CKD. T2DM at age 19.
Other comorbid: HTN,
hyperlipidemia, obesity
(BMI 38 kg/m2).
Past Hx: two
pregnancies complicated
by preeclampsia and
underwent menopause
at the age of 39.
She has no history of
CVE, but a chest CT
performed 1 years ago
showed incidental
coronary artery
calcification.

3. Labs
• eGFR was 54 ml/min per 1.73 m2
• UACR was 360 mg/g.
5 years ago:
• eGFR 24 ml/min per 1.73 m2
• UACR of 1200 mg/g
• Serum potassium is 4.8 mEq/L
• HbA1c is 8.2%
• Total cholesterol of 177 mg/dl, HDL cholesterol of 32 mg/dl, triglycerides of 255
mg/dl, and LDL cholesterol of 94 mg/d
• BP is 142/94 mm Hg.
Currently:

4. Treatment
lisinopril 40 mg/d
amlodipine 5 mg/d
atorvastatin 20 mg/d
metformin 500 mg/d
insulin glargine 15–20 units nightly

5. HOW WOULD YOU OPTIMIZE
THE MANAGEMENT OF THIS
PATIENT?

6. • CV risk
• women-specific risk-enhancing factors of preeclampsia and early menopause
• diabetes-related risk factors with long duration of type 2 diabetes >10 years,
macroalbuminuria, and low eGFR
• detection of coronary artery calcification indicates the presence of subclinical
coronary atherosclerosis
• Risk of kidney failure

7. RECOMMENDATIONS ?

8. Treatment
lisinopril 40 mg/d
amlodipine 5 mg/d
atorvastatin 20 mg/d
metformin 500 mg/d
insulin glargine 15–20 units nightly

9. Recommendations ?
High intensity statin (atorvastatin
40 - 80 mg)
• Note that rosuvastatin can't be used in
eGFR less than 30
Better BP control (target >130/80)
Aspirin for CVD prevention
Counseling on diet and increasing
physical activity

10. For T2DM
and CKD
progression
ACEi
rapid eGFR decline (54 – 24, >5
ml/min per 1.73 m2 per year)
• Might consider stopping Metformin
SGLT2i not recommended to be
initiated
??

11. What else to add?
• GLP1RA
• HbA1c 8.2%
• You are stopping Metformin
• BMI 38
• benefits in reducing atherosclerotic cardiovascular events in
cardiovascular outcome trials.
• also reduces albuminuria and may slow eGFR decline
• Decrease body weight

12. GLP1RA
GLP1RAs reduce risk of MACEs in patients with T2DM, as has
been demonstrated for liraglutide, semaglutide, albiglutide, and
dulaglutide.
In the LEADER trial, the RR for the MACE outcome conferred
by liraglutide was even greater among individuals with
eGFR<60 ml/min per 1.73 m2 compared with those with
eGFR≥60 ml/min per 1.73 m2 (HR, 0.69; [95% CI], 0.57 to 0.85
versus HR, 0.94; 95% CI, 0.83 to 1.07; P =0.01)

13. Kidney
outcomes
Although there has not been a completed
kidney outcome trial for GLP1RA, the
cardiovascular outcome trials of GLP1RA
have included patients with eGFR as low as
15 ml/min per 1.73 m2 with secondary
outcomes for kidney disease.
In a meta-analysis of 7 CV outcome trials,
GLP1RA reduced risk for a composite
kidney outcome (macroalbuminuria, eGFR
decline, progression to kidney failure, or
death from kidney disease) by 17% (HR,
0.83; 95% CI, 0.78 to 0.89) compared with
placebo, which was largely driven by
albuminuria reduction

14. Even safer than insulin with advanced
CKD
The AWARD-7 trial evaluated a GLP1RA among patients with
moderate to severe CKD (stages 3 and 4), comparing
dulaglutide with insulin glargine as basal therapy for
hyperglycemia.
Dulaglutide produced similar glycemic control to insulin but
with lesser eGFR decline. Notably, dulaglutide was safe in
moderate to severe CKD and reduced hemoglobin A1c to a
goal of 7%–7.5% with a 50% reduction in hypoglycemia rates.

15. Back to the patient:
D.C Metformin
D.C Insulin to
avoid
hypoglycemia with
advanced CKD
Add Liraglutide Add aspirin
Increase statin to
higher dose
Increase
amlodipine to 10
mg for more
control of BP
Diet and exercise
counselling