Chronic kidney disease (CKD) and cardiovascular disease (CVD) are among the most serious complications faced by people with type 2 diabetes (T2D). Not only do these conditions significantly increase morbidity and mortality, they also amplify the complexity of diabetes management. For pharmacists, staying updated on the latest evidence-based interventions and recommendations is essential to optimize patient care.
This blog post explores the links between CKD, CVD, and T2D, examines risk factors and treatment considerations, and highlights actionable strategies for pharmacists aiming to make a meaningful impact on patient outcomes.
Understanding the Connection Between T2D, CKD, and CVD
The Prevalence of CKD and CVD in T2D Patients
Diabetes is a leading cause of CKD and significantly accelerates the progression of cardiovascular complications. It’s estimated that up to 50% of people with diabetes will show signs of renal damage during their lifetime, and CVD accounts for nearly 50% of all diabetes-related deaths. These alarming statistics underline the critical need for pharmacists to proactively monitor and manage these risks.
How Diabetes Contributes to CKD and CVD
The development of CKD and CVD in T2D patients often stems from chronic hyperglycemia, which can lead to damage in blood vessels and organ tissues. Persistent glycemic dysregulation contributes to increased blood pressure, dyslipidemia, and inflammation, which further exacerbate vascular and renal damage.
The ABCDESSS Framework
Managing diabetes today goes well beyond blood sugar. The ABCDESSS framework is your quick reference for protecting patients with diabetes from cardiovascular and renal complications, and pharmacists are in a prime position to support every step.
A: A1C Goals: Know Your Targets
- Aim for ≤7.0% for most adults.
- Go tighter (≤6.5% or even <6.0%) in select type 2 patients aiming for remission—if safe.
- If on insulin or secretagogues: Screen for hypoglycemia and reinforce driving safety.
B: Blood Pressure: Keep It Under Control
- Goal: <130/80 mmHg
- If treated, check for fall risk, especially in older adults.
C: Cholesterol: Lower Is Better
- Target LDL-C: <2.0 mmol/L or >50% reduction
- Other acceptable targets:
- non-HDL <2.6 mmol/L
- ApoB <0.8 g/L
D: Drugs for CV & Renal Protection
Pharmacists are key in ensuring high-risk patients are on the right meds:
Antihyperglycemics with CV/renal benefits:
- SGLT2i or GLP-1 RA for type 2 diabetes + ASCVD, CKD, HF—or age >60 with ≥2 risk factors
Non-antihyperglycemics:
- ACEi/ARB – if CVD, age ≥55 with risk, or diabetes complications
- Statin – age ≥40 with type 2, CVD, or complications
- ASA – only if established CVD
E: Exercise & Eating: Lifestyle Still Matters
- 150 min/week of moderate–vigorous aerobic activity
- Resistance training 2–3x/week
- Encourage a Mediterranean or low-GI diet
S: Screening for Complications: Stay Ahead
- ECG: Every 3–5 years if age >40 or with complications
- Foot exam: Yearly (or more if abnormal)
- Kidney: Annual eGFR + ACR
- Eyes:
- Type 1: Yearly
- Type 2: Every 1–2 years
S: Smoking Cessation: Ask. Advise. Assist.
- Ask permission to discuss
- Offer therapy, referrals, and ongoing support
S: Self-Management: Empower the Patient
- Help patients set goals and tackle barriers
- Screen for mental health, stress, or financial concerns that could affect adherence
Pharmacological Interventions for Risk Reduction
The Role of SGLT2 Inhibitors
Sodium-glucose cotransporter-2 (SGLT2) inhibitors have revolutionized the management of CKD and CVD in T2D patients. These agents not only improve glycemic control but also provide significant renal and cardiovascular protection.
Initiating SGLT2 inhibitors in patients with an eGFR ≥ 20 mL/min has been shown to reduce the risk of disease progression, heart failure hospitalizations, and mortality. Pharmacists should counsel patients on potential side effects, like an initial drop in eGFR, and emphasize the long-term benefits of these medications.
GLP-1 Receptor Agonists
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are another frontline therapy for patients with T2D at high cardiovascular risk. These agents effectively lower blood glucose, promote weight loss, and reduce major adverse cardiovascular events (MACE).
Nonsteroidal Mineralocorticoid Receptor Antagonists (nsMRAs)
For patients with CKD and albuminuria, the use of nsMRAs like finerenone is gaining attention. These agents have been proven to lower the risk of CKD progression while also offering cardiovascular protection. Monitoring for hyperkalemia is essential when initiating therapy.
Challenges in Guideline-Based Management
Managing T2D patients with CKD and CVD can be challenging, even for experienced clinicians. Common barriers include patient resistance to medication adjustments, the financial burden of newer therapies, and the complexity of keeping up with evolving guidelines. Pharmacists play an integral role in overcoming these challenges by simplifying treatment plans, educating patients, and offering cost-saving tips.
Practical Tips for Pharmacists
Monitoring and Counselling
- Kidney Function: Regularly monitor eGFR and ACR levels to assess CKD progression and guide therapy decisions.
- Medication Adherence: Simplify regimens, provide reminders, and address side effects to improve adherence.
- Patient Education: Help patients understand the long-term benefits of their medications for both glycemic control and organ protection.
Looking Ahead
The management of CKD and cardiovascular risk in T2D is advancing rapidly, with new evidence and therapies transforming the care landscape. Pharmacists are uniquely positioned to drive better outcomes by staying updated on the latest guidelines, advocating for multifaceted care approaches, and supporting patients every step of the way.
Expand your knowledge of T2D management with this free, 30-minute CCCEP-accredited course, Beyond Glycemic Management: The Pharmacist’s Role in Optimizing Cardiovascular and Renal Outcomes in People with Type 2 Diabetes.
