We have reviewed the guideline update prepared by Navaneethan et al. with great interest 1, which is important to create an algorithm with current treatment approaches for diabetic patients with chronic kidney disease. However, considering that older adults (>65) constitute approximately half of diabetic patients 2 and , we think that there are a couple of special issues that need to be considered for elderly patients in the guideline update.

To begin with, the decrease in regeneration and functional performance with aging is more pronounced and serious in diabetes mellitus 3. It is known that elderly patients with impaired renal function are vulnerable to the hypoglycemia which is significant side effect of sulfonylureas 4 and that hypoglycemia can cause many problems such as impaired cognitive function, falls, stroke, cardiovascular events and even death in the elderly 5,6. Considering these facts, switching to another drug which has less risk of hypoglycemia, rather than reducing the dose of sulfonylurea in older adults may be more appropriate strategy.

Additionally, although SGLT-2 inhibitors provide significant advantages such as reduction of HbA1c, weight loss, reduction in the severity of renal failure, and positive cardiac effects, side effects such as orthostatic hypotension, dehydration, and development of urinary tract infection (UTI) were more likely to occur in elderly patients 7. Of  them, UTI is a significant cause of morbidity in older adults 8. Age is a risk factor for UTI in itself, due to increased urinary incontinence, urinary retention, hospitalizations, concomitant urinary catheterizations rates and immunosenesence with aging 9.

Moreover, orthostatic hypotension is significantly associated with a range of adverse cardiovascular, cognitive, and mortality outcomes in elderly patients10.  In this regard, older adults which have increased risk of UTI, orthostatic hypotension, should be evaluated individually for treatment.

In conclusion, it is clear that the current guideline will be beneficial to healthcare professionals in the management of diabetic patients with chronic kidney disease. Furthermore, considering the aforementioned concerns, we believe that the guideline may be more useful for geriatric practice, and so it is possible that elderly diabetics with CKD may more benefit from the treatment individualized for them.

References

1. Navaneethan SD, Zoungas S, Caramori ML, et al. Diabetes Management in Chronic Kidney Disease: Synopsis of the KDIGO 2022 Clinical Practice Guideline Update. Ann Intern Med. Published online 2023.
2. Bellary S, Kyrou I, Brown JE, Bailey CJ. Type 2 diabetes mellitus in older adults: clinical considerations and management. Nat Rev Endocrinol. 2021;17(9):534-548.
3. Guo J, Zheng HJ, Zhang W, et al. Accelerated Kidney Aging in Diabetes Mellitus. Oxid Med Cell Longev. 2020;2020:1234059. doi:10.1155/2020/1234059
4. Schernthaner G, Schernthaner-Reiter MH. Diabetes in the older patient: heterogeneity requires individualisation of therapeutic strategies. Diabetologia. 2018;61(7):1503-1516. doi:10.1007/s00125-018-4547-9
5. Dokuzlar O, Koc Okudur S, Smith L, et al. Assessment of factors that increase risk of falling in older women by four different clinical methods. Aging Clin Exp Res. 2020;32(3):483-490. doi:10.1007/s40520-019-01220-8
6. Ishikawa T, Koshizaka M, Maezawa Y, et al. Continuous glucose monitoring reveals hypoglycemia risk in elderly patients with type 2 diabetes mellitus. J Diabetes Investig. 2018;9(1):69-74. doi:10.1111/jdi.12676
7. Scheen AJ. Pharmacodynamics, Efficacy and Safety of Sodium–Glucose Co-Transporter Type 2 (SGLT2) Inhibitors for the Treatment of Type 2 Diabetes Mellitus. Drugs. 2015;75(1):33-59. doi:10.1007/s40265-014-0337-y
8. Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults. Infect Dis Clin North Am. 2017;31(4):673-688. doi:10.1016/j.idc.2017.07.002
9. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(5):625-663.
10. Kocyigit SE, Soysal P, Bulut EA, Aydin AE, Dokuzlar O, Isik AT. What is the relationship between frailty and orthostatic hypotension in older adults? J Geriatr Cardiol. 2019;16(3):272-279. doi:10.11909/j.issn.1671-5411.2019.03.005