Multidisciplinary Delphi study on residual risk in patients with chronic kidney disease and type 2 diabetes mellitus

Abstract

BACKGROUND AND OBJETIVE: Currently, patients with chronic kidney disease (CKD) and type-2 diabetes mellitus (T2DM) present a persistent residual renal and cardiovascular (CV) risk despite receiving standard treatment. Therefore, the aim was to assess the degree of multidisciplinary consensus on the persistent residual risk in these patients and its possible therapeutic approach. MATERIALS AND METHODS: A Scientific Committee of 4 experts accustomed to the management of CKD and T2DM proposed the content of a Delphi questionnaire and the profile of panelists and validated the final questionnaire. A panel composed of 60 specialists in Nephrology (n = 20), Endocrinology (n = 20) and Primary Care (n = 20) completed the questionnaire specifically designed for the study, which contained 76 statements generated after a targeted literature review, to which 2 more statements were added for the second round. Using Delphi methodology adapted between May and June 2024, the panel assessed the statements included in the questionnaire in 2 rounds. Each statement was to be rated on an ordinal Likert-type scale from 1 to 9 points. RESULTS: A response was obtained from 60 specialists in the 2 rounds of the study. Seventy-two percent of the panelists had more than 15 years of experience, 70.0% followed more than 25 patients with CKD and T2DM monthly, and all belonged to a scientific society. In the first Delphi round, the defined level of agreement was reached for 43 statements and in the second round for 10 additional statements [53/78 (68%) consensus statements]. The section with consensus on the largest number of statements was residual risk (86.4%). In this block, the predefined level of agreement was reached in aspects such as elevated risk of renal complications (median; interquartile range: 9 [8-9]), CV (9 [8-9]) or premature death (9 [8-9]) despite receiving standard treatment, the complementary action of different drugs with different mechanism of action (9 [9-9]), the simultaneous establishment of 3 pillars of treatment [renin-angiotensin system blockade + SGLT2 inhibitors (iSGLT2)+Non-steroidal Mineralocorticoid Receptor Antagonists (mRNAs)] (8 [7-9]), the progress made by iSGLT2 (9 [9-9]) and ARMn (8 [7-9]) in renal and CV protection, and the need to avoid therapeutic inertia (9 [8-9]), use treatments early and intensively (9 [8-9]) and coordination between levels of care (9 [9-9]). CONCLUSIONS: Multidisciplinary consensus was obtained that patients with T2DM and CKD present a high residual risk of disease progression, premature death, renal and CV complications. The simultaneous implementation of the 3 pillars of treatment, the avoidance of therapeutic inertia, and coordination between levels of care are considered relevant measures to contribute to reducing the residual risk in these patients.