| Chronic kidney disease (adjunctive agent): Dapagliflozin [Forxiga] 1차 약제로 치료 중임에도 지속적으로 알부민뇨 (urine albumin-to-creatinine ratio 200 to 5,000 mg/g)가 있는 환자에서 2차 약제로 사용될 수 있습니다. 이러한 이득은 당뇨병 유무와 관련 없이 지속적으로 입증되었습니다. |
당뇨병성 콩팥병증으로 단백뇨가 있는 환자에서 ARB 또는 ACEI를 사용합니다. 이것에 더하여 SGLT2 억제제 치료를 제안합니다.
| 당뇨병이 있고 DKD (diabetic kidney disease)가 있는 대부분의 환자에서 SGLT2 억제제 치료 효과는 분명합니다. eGFR이 최종적으로 25 미만으로 떨어지는 환자들에서도 지속적으로 안전하게 사용될 수 있지만 일반적으로 eGFR이 25-30 미만인 경우에는 SGLT2 억제제 사용 시작을 피해야 합니다. 또한 이전에 하지 절단이나 현재 절단 위험이 있는 경우 (예, 하지 궤양과 말초혈관질환)에도 주의하며 사용해야 합니다. |
SGLT2 억제제는 ESKD를 포함한 콩팥 종말 합병증을 예방할 수 있습니다. ★★ 비록 severely increased albuminuria가 있든 없든 상대적인 콩팥부전 위험 감소는 비슷하겠지만, 절대적 위험 감소는 severely increased albuminuria에서 더 큽니다. 왜냐하면 그와 같은 환자들이 주된 콩팥 사건 발생 위험이 절대적으로 더 높기 때문입니다. ★★
★★ 따라서 알부민뇨가 있는 환자에서 SGLT2 사용을 권고하는 강도는 정상 또는 moderately increased albuminuria 환자보다 severely increased albuminuria 환자에서 더 높습니다. ★★
Overview of the management of diabetic kidney disease
ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; eGFR: estimated glomerular filtration rate; SGLT2: sodium-glucose co-transporter 2.
* More (versus less) intensive blood pressure goals are typically recommended in patients with diabetes. Refer to UpToDate content on treatment of hypertension in diabetic patients and on goal blood pressure in adults.
¶ Glycemic control targets are typically individualized, but an A1c goal of <7% is frequently recommended. Refer to UpToDate content on glycemic control in patients with type 1 and type 2 diabetes.
Δ Most patients with diabetic kidney disease are at high cardiovascular risk and therefore should be treated with statin therapy. Refer to UpToDate content on low-density lipoprotein cholesterol lowering for primary and secondary, and on medical, care of diabetic patients.
◊ After adjusting the patient's therapy and measuring the response at an appropriate time interval, this algorithm can be used again to make further adjustments to the therapeutic regimen (if not already maximized). Reduced dietary sodium and/or use of a diuretic, in combination with an ACE inhibitor or ARB, can increase the likelihood of achieving proteinuria goals.
§ SGLT2 inhibitors increase the risk of genital infections and may also be associated with a higher incidence of lower limb amputations (although such complications are uncommon). Patients with a prior history of or risk factors for genital infections or lower limb amputation may reasonably choose to not take an SGLT2 inhibitor.
¥ SGLT2 inhibitors reduce the risk of kidney disease progression and end-stage renal disease in patients with diabetic kidney disease, regardless of the degree of proteinuria. However, patients with severely increased albuminuria (albumin-to-creatinine ratio ≥300 mg/g) are at higher risk for kidney disease progression and end-stage renal disease and therefore derive a greater absolute benefit from therapy with SGLT2 inhibitors. Patients with normoalbuminuria or moderately increased albuminuria have a lower absolute risk for progression and therefore derive a smaller absolute benefit. Thus, for some patients at lower absolute risk for progression, the benefits and harms of taking an SGLT2 inhibitor may be more closely balanced.
Ref. UpToDate 2021.07.07