Diabetic Kidney Disease,

What Do We Know so Far?

Made Ratna Saraswati
4 September 2022
Disclosure
I have received honorarium as speaker/consultant, support for
research/attendance at educational meetings from :
(per alphabet)
• Astra Zeneca
• Darya Varia
• Kalbe
• Merck
• Novo Nordisk
• Sanofi
@ratnasrswt
• Sintesa
• Takeda
• Zuellig Pharma
Disclaimer

• This event is a non-promotional event, sponsored by AstraZeneca Indonesia which may

contains off label information.
• During this event, data may refer to medicines or indications that may not be approved
in Indonesia. They are presented in the spirit of education and the right of the scientific
and medical community to be fully informed concerning scientific and medical progress.
The information should under no circumstances be regarded as a recommendation for
use of the medicine or indication.

© AstraZeneca 2022
Diabetic
Kidney
Disease,
What Do We
Know so Far?

© AstraZeneca 2022
 What’s in store for us today?
1 2 3 4
Diabetes in Indonesia Diabetes Complication
- Diabetic Kidney
Disease
Diabetic Kidney
What are the numbers Disease as one of the
showing how good/bad most common
we are doing in complications is still
Managing Type 2 underdiagnosed, and its
Diabetes Melitus burden increase both
morbidity and mortality
Prevention of Kidney Clinical
Disease Consideration
DECLARE TIMI 58 What are the guidelines
shows promise in saying about DKD
preventing the
progression of Kidney
Disease in Type 2
Diabetes Melitus patients
© AstraZeneca 2022
Diabetes in Indonesia
Diabetes Complication – Diabetic Kidney Disease
Prevention of Kidney Disease
Clinical Consideration
 Diabetes in Indonesia

8 T2DM : Type 2 Diabetes Melitus; 1. IDF Diabetes Atlas 2021; 2. Ji L et al. 53rd EASD, 11–15 September 2017, Lisbon, Portugal. © AstraZeneca 2022
Diabetes in Indonesia
Diabetes Complication – Diabetic Kidney Disease
Prevention of Kidney Disease
Clinical Consideration
T2D plays a central role in the development and progression of
cardiovascular and renal disease

PUMP HEART
FAILURE

Diabetes PIPES ASCVD

affects

FILTER KIDNEY
DISEASE

Diabetes is complex disease involving multiple organ systems

ASCVD, atherosclerotic cardiovascular disease; T2D, type 2 diabetes

Verma S et al. Lancet. 2018;393:3–5 © AstraZeneca 2022
CKD is the most common initial comorbidity in patients with T2D,
but remains significantly underdiagnosed

CKD is over 1.6 times more likely to manifest

in patients with T2D compared with CVD1
Frequency of first manifestation (%)

40
52% 94% 82%
35

30 37%
USA, TriNetX2 France3 Japan3
25

20
23%
15 74% 74%
10 17%
14% Undiagnosed
5 Diagnosed Italy4 Germany5
10%
0
CKD HF Stroke MI PAD Up to 94% of patients with T2D
are undiagnosed at stage 3 CKD2-5
1. Norhammer A et al. Diabetes Obes Metab. 2022;24(7):1277-1287; 2. Sultan AA et al. Poster presented at: ADA 81 st Scientific Sessions (Virtual Meeting); June 25-29, 2020; Poster 988-P; 3. Virgitti JB
et al. Poster presented at: ASN Kidney Week (Virtual Meeting); November 4-7, 2021; Poster PO2337; 4. de Nicola et al. Presented at: ERA Congress; May 19-22, 2022; Paris, France.
Presentation MO509; 5. Schneider M et al. Poster presented at: WCN (Virtual Meeting); February 24-27, 2022; Poster WCN22-0472.
© AstraZeneca 2022
Bagaimana kita sebaiknya melakukan penapisan
terhadap resiko CKD pada pasien T2DM kita?

Underdiagnosed?

CKD : Chronic Kidney Disease T2DM : Type 2 Diabetes Melitus

© AstraZeneca 2022
eGFR (measure of renal function) and UACR (measure of renal damage)
are critical for CKD diagnosis and risk stratification

GFR (mL/min/1.73 m2) UACR (mg/g)

CKD is classified based on cause,
G1 GFR category,
≥90 A1 and albuminuria category1
<30
G2
60-89
CKD screening and risk stratification
must consist of a dual assessment of
G3 30-59 30-300 A2 eGFR and UACR2

G4 15-29
Patients with T2D should be screened
>300 A3 for CKD at least once yearly
G5 <15
using eGFR and UACR assessments3

1. Kidney Disease: Improving Global Outcomes. Kidney Int. 2020;98(4S):S1-S115; 2. Shlipak MG et al. Kidney Int. 2021;99(1):34-47; 3. American Diabetes Association. Diabetes Care.
2022;45(suppl 1):S175-S184. © AstraZeneca 2022
 Optimal Risk Factor Management
Does Not Eliminate Risk of Diabetic Nephropathya
Treatment goals for standard and intensive treatment
groups1
Residual nephropathy risk in patients randomized to
multifactorial intensive medical therapy2
Conventional Intensive
60

Proportion of patients with nephropathy (%)

Systolic BP (mm Hg) <160 <140b
Conventional treatment
50
Intensive treatment
Diastolic BP (mm Hg) <95 <85
46

HbA1c (%) <7.5 <6.5c

39
40 RR: 0.44
(95% CI: 0.25–0.77)
Triglycerides (mmol/L) <2.2 <1.7d
p=0.004
30
Total cholesterol (mmol/L) <6.5 <5.0 e 24 25
20
HDL cholesterol (mmol/L) >0.9 >1.1 20

ACE inhibitor irrespective of BP No Yes 10

10
Aspirin in patients with known ischemia Yes Yes
Residual risk
Aspirin in patients with peripheral vascular
No Yes
0
disease 3.8 7.8 13.3
Vitamin C and E supplement No Yes Follow-up (years)
a
Diabetic nephropathy was defined as a urinary albumin excretion of more than 300 mg/24 hours in two of three consecutive sterile urine specimens 2; bHypertension was treated with ACE inhibitors as initial treatment with
angiotensin-II receptor antagonist used if adverse events. Thiazides, calcium-channel blockers, and beta-blockers added as needed; cAntidiabetic therapy with metformin, gliclazide, and/or insulin; dHypertriglyceridemia treatment
with fibrate; eDyslipidemia treatment with statin.
1. Gaede P et al. Lancet. 1999;353:617–622; 2. Fioretto P et al. Nat Rev Endocrinol. 2010;6:19–25. © AstraZeneca 2022
 The risks of mortality, CV events, and ESKD are high
in patients with CKD and even higher in those with concomitant T2D

For patients with CKD and diabetes, Patients with CKD and diabetes are more likely to…
the risk of all-cause mortality is almost double1

31%
Kidney

! !
disease and
17% diabetes
Kidney
disease
Experience CV events2,a Progress to ESKD3
only

…than those without diabetes

Most patients with CKD and T2D die before reaching dialysis3

a
Myocardial infarction or stroke.
16 1. Afkarian M et al. J Am Soc Nephrol. 2013;24(2):302-308; 2. Currie CJ et al. PLoS One. 2019;14(8):e0221044; 3. Fox CS et al. Lancet. 2012;380(9854):1662-1673. © AstraZeneca 2022
 In the Presence of T2D, Lower eGFR and Higher Albuminuria
Independently Predict Higher Mortality

All-cause mortality according to eGFR in All-cause mortality according to ACR in

participants with and without diabetes participants with and without diabetes
8.0 8.0

Adjusted Hazard Ratio (95%

Adjusted Hazard Ratio (95%

4.0 4.0

CI)
CI)

2.0 2.0

1.5 1.5

1.0 1.0
Decreasing Development of
eGFR Albuminuria
0 0
15 30 45 60 75 90 10 12 2.5 5 10 30 300 1000
eGFR (mL/min per 1.73 m2) 5 0 ACR (mg/g)
Diabetes Non-diabetes
ACR = albumin-to-creatinine ratio; eGFR = estimated glomerular filtration rate; T2D = type 2 diabetes.
Fox C et al. Lancet. 2012;380:1662-1673. © AstraZeneca 2022
Diabetes in Indonesia
Diabetes Complication – Diabetic Kidney Disease
Prevention of Kidney Disease
Clinical Consideration
DECLARE: An Assessment of CV Effects of Dapagliflozin in a Broad CV
Risk Population with Type 2 Diabetes1,2
T2D plus: Composite of
Multiple CV Risk Factors (≥2)
• Age ≥55 males; ≥60 females AND at least Placebo CV death, MI, stroke (MACE)

Two Primary Endpoints

one of the following:
– Hypertension
– Dyslipidemia

Double-blind
– Tobacco use

1:1
n=10,186

Established CVD Composite of

• Age ≥40 years AND one of the following:
– Ischemic heart disease
Dapagliflozin
– Cerebrovascular disease CV death or hHF
– Peripheral arterial disease (10 mg per day)

n=6,974

N=17,160 Secondary Endpoints

• Cardiorenal composite endpointa
• All-cause mortality

• Add on to background CV and GLD per treating physician

• Event-driven (≥1390 events), median duration ~4.2 years

a
≥40% decrease in estimated glomerular filtration rate to <60 ml/min/1.73 m 2, new end-stage kidney disease, or renal or CV death.
CV = cardiovascular; CVD = cardiovascular disease; DECLARE = The Dapagliflozin Effect on Cardiovascular Events; GLD = glucose-lowering drug; hHF = hospitalization for heart failure;
MACE = major adverse cardiovascular event; MI = myocardial infarction; T2D = type 2 diabetes.
1. Wiviott SD, et al. Am Heart J. 2018;200:83-89; 2. Wiviott SD, et al. N Engl J Med. 2019;380(4):347-357. © AstraZeneca 2022
 DECLARE Enrolled Patients Early in the Disease Continuum With
Predominantly Preserved Renal Function1,2

Micro-/macro- Renal composite

eGFRa, mean
albuminuria (Placebo rate per Renal composite definition
(mL/min/1.73 m2)
(%) 1000 pt-yrs)

≥40% decrease in eGFR to

DECLARE1,2 85.2 30.9b 7.0
<60 mL/min/1.73 m2, ESKD, or renal death

40% reduction in eGFR, renal-replacement

CANVAS3 76.5 30.2 9.0
therapy, or renal death

Doubling SCr accompanied by eGFR of

EMPA-REG4,5 74c 39.6 11.5 ≤45 mL/min/1.73 m2, renal-replacement
therapy, or renal death

Doubling SCr, renal-replacement therapy, or

VERTIS-CV6,7 76 39.4 12.0
renal death

a
eGFR Calculations: DECLARE CKD-EPI; EMPA-REG, CANVAS, and VERTIS-CV MDRD; bUACR was not measured at baseline for all patients; cBased on a pre-final version of the database (N=7034).
eGFR = estimated glomerular filtration rate; ESKD = end-stage kidney disease; pt-yr = patient-years; SCr = serum creatinine; UACR = urinary albumin-to-creatinine ratio.
1. Wiviott SD et al. N Engl J Med. 2019;380:347-357; 2. Mosenzon O et al. Lancet Diabetes Endocrinol. 2019;7:606-617; 3. Neal B et al. N Engl J Med. 2017;377:644-657; 4. Zinman B et al. N Engl J Med. 2015;373:2117-2128; 5.
Wanner C et al. N Engl J Med. 2016;375:323-334; 6. Cannon CP et al. Am Heart J. 2018;206:11-23; 7. Cannon CP et al. N Engl J Med. 2020;383:1425-1435.
© AstraZeneca 2022
DECLARE Showed That Dapagliflozin Slowed Renal Disease Progression a
in Patients With T2D With Predominantly Preserved Renal Function
Sustained eGFR decrease ≥40% to eGFR <60 ml/min/1.73 m2,
0.06
ESKDb, or Renal Death

0.05 HR 95% CI p-valuec

Cumulative Probability of Event 0.53 (0.43, 0.66) <0.0001

0.04

0.03
Placebo (2.8%)

0.02
DAPA 10 mg (1.5%)

0.01

0.00
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Years since randomization
No. at risk
DAPA 10 mg 8582 8523 8422 8338 8242 8127 8004 7522 5464
Placebo 8578 8504 8415 8321 8193 8056 7925 7403 5382

a
Prespecified exploratory endpoint; bESKD defined as dialysis ≥90 days or kidney transplantation, or sustained confirmed eGFR <15 ml/min/1.73 m2 ; cBecause the trial met only one of its dual primary outcomes for superiority (CV death or hospital
admission for heart failure), all other analyses of additional outcomes should be considered hypothesis generating only. No. at risk is the number of subjects at risk at the beginning of the period.
DAPA = dapagliflozin; eGFR = estimated glomerular filtration rate; ESKD = end-stage kidney disease; HR = hazard ratio; T2D = type 2 diabetes.
Mosenzon O et al. Lancet Diabetes Endocrinol. 2019;7:606-617.
© AstraZeneca 2022
 DECLARE: Reductions Were Demonstrated Across All Clinically Important Components
of the Renal-Specific Compositea, Including ESKD and Renal Deathb

Dapagliflozin
Dapagliflozin Placebo
Placebo
KM
KMEvent
Event Rate
Rate KMEvent
KM EventRate
Rate Hazard Ratio
Hazard Ratio
n/N n/N
(%) (%) (4
(4 years)
years) n/N (%) (4 years)
(4 years) (95% CI)(95% CI) P value
p-value
Secondary Renal Composite Outcome
eGFR decrease ≥40% to <60; ESKD;
370/8582 (4.3) 4.2% 480/8578 (5.6) 5.3% 0.76 (0.67-0.87) <0.0001
or renal or CV death

Renal-specific Outcome
eGFR decrease ≥40% to <60; ESKD;
127/8582 (1.5) 1.5% 238/8578 (2.8) 2.6% 0.53 (0.43-0.66) <0.0001
or renal death

Individual Components
eGFR decrease ≥40% to <60 120/8582 (1.4) 1.4% 221/8578 (2.6) 2.5% 0.54 (0.43-0.67) <0.0001

End stage kidney disease (ESKD) 6/8582 (0.1) 0.1% 19/8578 (0.2) 0.2% 0.31 (0.13-0.79) 0.013

Renal death 6/8582 (0.1) 0.1% 10/8578 (0.1) 0.1% 0.60 (0.22-1.65) 0.32

CV death 245/8582 (2.9) 2.7% 249/8578 (2.9) 2.7% 0.98 (0.82-1.17) 0.83

ESKD or renal death 11/8582 (2.9) 0.1% 27/8578 (0.3) 0.3% 0.41 (0.20-0.82) 0.012

0.1 0.5 1.0 1.7

DAPA 10 mg Better Placebo Better

a
Prespecified exploratory endpoint: decrease eGFR ≥40% to <60 mL/min/1.73 m 2, ESKD or Renal Death; bBecause the trial met only one of its dual primary outcomes for superiority (CV death or
hospital admission for heart failure), all other analyses of additional outcomes should be considered hypothesis generating only.
CV = cardiovascular; DAPA = dapagliflozin; eGFR = estimated glomerular filtration rate; ESKD = end-stage kidney disease; KM = Kaplan Meier.
22 Mosenzon O et al. Lancet Diabetes Endocrinol. 2019;7:606-617. © AstraZeneca 2022
 The cardiorenal benefits of dapagliflozin extend to patients with
T2D and early renal disease in the DECLARE-TIMI 58 trial

UACR2 (mg/g) Renal-specific Composite of

composite outcome3,b CV death or hHF4,c
Early intervention in
<30 48% 10%
patients with T2D
to prevent cardiorenal (68% RRR RRR
complications1,a of patients)
30-300 41% 24%
N=17,160 (23% RRR RRR
of patients)
1:1 randomization >300 62% 23%
(7% of RRR RRR
patients)
DAPA 10 mg Placebo
Dapagliflozin demonstrated consistent cardiorenal
Median follow-up time: 4.2 years benefit in patients
with and without albuminuria d,e
a
Eligible patients had T2D, a CrCl of ≥60 mL/min, and MRFs for ASCVD or established ASCVD; bThis was a prespecified exploratory outcome defined as sustained eGFR decrease ≥40% to <60 mL/min/1.73 m 2,
ESKD, or death from renal causes; cEndpoint was one of the two primary endpoints of the trial; dThe p-value for interaction across UACR values was 0.30; eThe
p-value for interaction across UACR values was 0.47.
1. Wiviott SD et al. N Engl J Med. 2019;380(4):347-357; 2. Raz I et al. Diabetes Obes Metabl 2018;20(5):1102-1110; 3. Mosenzon O et al. Lancet Diabetes Endocrinol. 2019;7(8):606-617; 4. Zelniker TA et al. Article
and supplementary appendix. JAMA Cardiol. 2021;6(7):801-810. © AstraZeneca 2022
Diabetes in Indonesia
Diabetes Complication – Diabetic Kidney Disease
Prevention of Kidney Disease
Clinical Consideration
Dapagliflozin had a Favorable Effect on Albuminuria Across Baseline
UACR Categories, Including Patients with Normal Albumin Excretion1,2
Dapagliflozin Placebo
KM KM Hazard Ratio Cox
n/N (%) Event Rate n/N (%) Event Rate (95% CI) p-value
Improvement from baseline
Micro to Normo 774/2017 (38.4) 38.9% 576/2013 (28.6) 29.0% 1.46 (1.31, 1.62) <0.0001
Macro to Normo/Micro 282/594 (47.5) 48.1% 175/575 (30.4) 31.7% 1.82 (1.51, 2.2) <0.0001
Macro to Normo/Micro or Micro to Normo 1056/2611 (40.4) 41.0% 751/2588 (29.0) 29.5% 1.54 (1.4, 1.69) <0.0001
Micro/Macro to Normo 809/2611 (31.0) 31.5% 604/2588 (23.3) 23.6% 1.41 (1.27, 1.56) <0.0001
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0
Favors Favors
Placebo DAPA

Deterioration from baseline

Normo/Micro to Macro 181/7836 (2.3) 2.3% 330/7838 (4.2) 4.2% 0.54 (0.45, 0.65) <0.0001
Normo to Micro/Macro 772/5819 (13.3) 13.3% 959/5825 (16.5) 16.3% 0.79 (0.72, 0.87) <0.0001
Normo to Micro/Macro or Micro to Macro 928/7836 (11.8) 11.9% 1243/7838 (15.9) 15.8% 0.73 (0.67, 0.79) <0.0001

0.0 0.5 1.0 1.5

Definitions of Albuminuria Categories Worse for Placebo Worse for DAPA

Macroalbuminuria UACR ≥300 mg/g

Microalbuminuria UACR ≥30 to <300 mg/g
Normoalbuminuria UACR <30 mg/g

DAPA = dapagliflozin; KM = Kaplan-Meier; Macro = macroalbuminuria; Micro = microalbuminuria; ; Normo = normoalbuminuria; UACR = urinary albumin-to-creatinine ratio.
1. Raz I et al. Presented at: ADA 79th Scientific Sessions; June 7-11, 2019; San Francisco, CA. 244-OR. 2. Mosenzon O et al. Diabetes Care. 2021;44:1-11. © AstraZeneca 2022
 ADA 2021 Standards of Care
Antihyperglycemic Medication in T2D: Overall Approach
First-Line Therapy is Metformin and Comprehensive Lifestyle (including weight management and physical activity)

Indicators of High-Risk or Established ASCVD, CKD or HF a NO

Consider Independently of Baseline A1C, Individualized A1C Target, or Metformin Use b

+ASCVD/INDICATORS of High Risk +HF +CKD If A1C Above Individualized Target, Proceed as Below
Particularly HFrEF DKD and NO
• Established ASCVD
(LVEF <45%) Albuminuriaj COMPELLING NEED TO MINIMIZE HYPOGLYCEMIA COMPELLING NEED TO MINIMIZE WEIGHT GAIN OR
• Indicators of high ASCVD risk COST IS A MAJOR ISSUEm,n
(age≥55 years with coronary, PROMOTE WEIGHT LOSS
carotid, or lower extremity PREFERABLY DPP-4i GLP-1 RA SGLT2i TZD GLP-1 RA with
SGLT2i with EITHER/
artery stenosis >50%, or LVH) SGLT2i with primary good efficacy for weight SGLT2i SUf TZDn
proven benefit in evidence of reducing CKD OR
this populationg,h,i lossl
progression

OR If A1C above If A1C above If A1C above If A1C above

EITHER/
OR target target target target If A1C above If A1C above If A1C above If A1C above
GLP-1 RA SGLT2i
with with SGLT2i with evidence of target target target target
proven proven reducing CKD
progression in CVOTsg,h,j
CVD CVD SGLT2i SGLT2i GLP-1 RA SGLT2i
benefitc benefitc GLP-1 RA with
OR OR OR OR
OR SGLT2i good efficacy for
GLP-1 RA with proven CVD DPP-4i DPP-4i weight lossl TZDn SUf
benefitc if SGLT2i not TZD TZD
If A1C above target OR
tolerated or contraindicated OR
TZD GLP-1 RA
For patients with T2D and If A1C above If A1C above
If further intensification is required CKDj (e.g., eGFR target target If A1C above If A1C above
or patient is unable to tolerate <60 mL/min/1.73 m2) and thus If A1C above target target target
GLP-1 RA and/or SGLT2i, choose at increased risk of
agents demonstrating CV benefit cardiovascular events Continue with addition of other agents listed above If quadruple therapy required or SGLT2i and/or GLP-1 RA not tolerated or
and/or safety: contraindicated, use regimen with lowest risk of weight gain.
• For patients on a GLP-1 RA, con- If A1C above target Preferably: DPP-4i (if not on GLP-1 RA) based on weight neutrality Insulin therapy basal insulin with
sider adding SGLT2i with proven EITHER/
lowest acquisition cost
CVD benefit and vice versa c OR Consider addition of SUf or basal insulin: OR
GLP-1 RA SGLT2i
• TZDd
with • Choose later generation SU with lower risk of hypoglycemia If DPP-4i not tolerated or contraindicated or patient already on GLP- Consider other therapies based on
• DPP-4i if not on GLP-1 RA with 1 RA, cautious addition of:
proven proven • Consider basal insulin with lower risk of hypoglycemiak cost
• Basal insuline -SUf -TZDd - Basal Insulin
CVD CVD
• SUf
benefitc benefitc,i

To avoid therapeutic inertia reassess and modify treatment regularly (3-6 months). aActioned whenever these become new clinical considerations regardless of background glucose-lowering medications; bMost patients enrolled in the relevant trials were on metformin at baseline as glucose-lowering therapy; cProven CVD benefit means it has label indication of reducing CVD events; dLow dose may be better tolerated though less
well studied for CVD effects; eDegludec or U100 glargine have demonstrated CVD safety; fChoose later generation SU to lower risk of hypoglycemia; glimepiride has shown similar CV safety to DPP-4i; gBe aware that the SGLT2 inhibitor labeling varies by region and individual agent with regard to indicated level of eGFR for initiation and continued use; hDapagliflozin, empagliflozin, and canagliflozin have shown reduction in HF and

© AstraZeneca 2022
reduction in CKD progression in CVOTs. Dapagliflozin and canagliflozin have primary renal outcome data. Dapagliflozin and empagliflozin have primary HF outcome data; iProven benefit means it has label indication of reducing HF in this population; jRefer to Section 11: Microvascular Complications and Foot Care; kDegludec/glargine U300 < glargine U100/detemir < NPH insulin lSemaglutide > liraglutide > dulaglutide > exenatide >
lixisenatide; mIf no specific comorbidities (ie, no established CVD, low risk of hypoglycemia, and lower priority to avoid weight gain or no weight-related comorbidities); nConsider country- and region-specific cost of drugs. In some countries TZDs are relatively more expensive and DPP-4i are relatively cheaper. American Diabetes Association. Diabetes Care. 2021;44(suppl 1):S1-S232.
 KDIGO 2020:
Most Patients With T2D, CKD, and eGFR ≥30 mL/min/1.73m2 Benefit From SGLT2
Inhibitor Treatment, Regardless of CKD Stage or Level of Glycemic Control
Physical activity
Lifestyle therapy SomeNutrition
patients
Weight loss
Antiplatelet
therapies
Most
Metformin patients SGLT2 inhibitor
First-line therapy eGFR <45: reduce dose eGFR <30: do not initiate
eGFR ≥30 mL/min/1.73m2
eGFR <30 or dialysis:
SGLT2 DC RAS Dialysis: DC
inhibitors blockade
All Choice of SGLT2 inhibitor
patients
should prioritize agents with
documented kidney or
cardiovascular benefits
Glycemic BP GLP-1
Lipid RA
control control management
(preferred)
Additional drug
therapy as needed for DPP-4i Insulin
Exercise Nutrition Smoking cessation
glycemic controla SU TZD
Diabetes with CKD
AG-i
a
Guided by patient preferences, comorbidities, eGFR and cost Includes patients with eGFR <30mLmin/1.73m2 or treated with dialysis
AG-i = alpha-glucosidase inhibitor; CKD = chronic kidney disease; D/C = discontinue; DPP-4i = dipeptidyl peptidase-4 inhibitor; eGFR = estimated glomerular filtration rate; GLP-1 RA =
glucagon-like peptide-1 receptor agonist; SGLT2 = sodium-glucose cotransporter 2; SU = sulfonylurea; T2D = type 2 diabetes; TZD = thiazolidinedione.
28 de Boer IH et al. Kidney International. 2020;98:839–848. © AstraZeneca 2022
PERKENI 2021

Pedoman dan Pencegahan Diabetes Melitus Dewasa Tipe 2 di Indonesia, PERKENI 2021 © AstraZeneca 2022
 Dapagliflozin is a recommended first-line therapy for patients with DKD,
independent of HbA1c

SGLT2 inhibitors, SGLT2 inhibitors should SGLT2 inhibitors should

alongside metformin, be given to all patients be given to all patients
are recommended as first- with CKD stage 3 or with T2D and
line therapy in patients higher and T2D, albuminuria or CKD
with T2D regardless stage 3, regardless
and CKD1 of glycemic control2 of glycemic control3

1. de Boer IH et al. Kidney Int. 2020;98(4):839-848; 2. American Diabetes Association. Diabetes Care. 2022;45(suppl 1):S175-S184;
3. Pedoman dan Pencegahan Diabetes Melitus Dewasa Tipe 2 di Indonesia, PERKENI 2021
30 . © AstraZeneca 2022
There is a need to diagnose and treat patients with CKD early
to transform their clinical outcomes

1 CKD is significantly underdiagnosed despite being one of the most common initial
comorbidities in patients with T2D1

2 The risks of mortality, CV events, and ESKD are high in patients with CKD and even
higher in those with concomitant T2D2,3,4

3 The latest KDIGO, ADA, PERKENI guidelines recommend dapagliflozin as first-line

therapy in patients with DKD, regardless of HbA 1c5,6,7

1. Norhammer A et al. Diabetes Obes Metab. 2022;24(7):1277-1287; 2. Afkarian M et al. J Am Soc Nephrol. 2013;24(2):302-308; 3. Currie CJ et al. PLoS One. 2019;14(8):e0221044; 4. Fox CS et al.
Lancet. 2012;380(9854):1662-1673.; 5. de Boer IH et al. Kidney Int. 2020;98(4):839-848; 6. American Diabetes Association. Diabetes Care. 2022;45(suppl 1):S175-S184.; 7. Pedoman dan Pencegahan
Diabetes Melitus Dewasa Tipe 2 di Indonesia, PERKENI 2021
© AstraZeneca 2022
MATUR SUKSMA