Diabetes Management in Chronic Kidney Disease (CKD)
KDIGO / ADA Consensus Statements
- All patients with type 1 diabetes (T1D) or type 2 diabetes (T2D) and CKD should be treated with a comprehensive plan, outlined and agreed by health care professionals and the patient together, to optimize nutrition, exercise, smoking cessation, and weight, upon which are layered evidence-based pharmacologic therapies aimed at preserving organ function and other therapies selected to attain intermediate targets for glycemia, blood pressure (BP), and lipids.
- An ACE inhibitor (ACEi) or angiotensin II receptor blocker (ARB) is recommended for patients with T1D or T2D who have hypertension and albuminuria, titrated to the maximum antihypertensive or highest tolerated dose.
- A statin is recommended for all patients with T1D or T2D and CKD, moderate intensity for primary prevention of atherosclerotic cardiovascular disease (ASCVD) or high intensity for patients with known ASCVD and some patients with multiple ASCVD risk factors.
- Metformin is recommended for patients with T2D, CKD, and estimated glomerular filtration rate (eGFR) $30 mL/min/1.73 m2; the dose should be reduced to 1,000 mg daily in patients with eGFR 30–44 mL/min/1.73 m2 and in some patients with eGFR 45–59 mL/min/1.73 m2 who are at high risk of lactic acidosis.
- A sodium–glucose cotransporter 2 inhibitor (SGLT2i) with proven kidney or cardiovascular benefit is recommended for patients with T2D, CKD, and eGFR $20 mL/min/1.73 m2. Once initiated, the SGLT2i can be continued at lower levels of eGFR.
- A glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended for patients with T2D and CKD who do not meet their individualized glycemic target with metformin and/or an SGLT2i or who are unable to use these drugs.
- A nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) with proven kidney and cardiovascular benefit is recommended for patients with T2D, eGFR $25 mL/min/1.73 m2, normal serum potassium concentration, and albuminuria (albumin-to-creatinine ratio [ACR] $30 mg/g) despite maximum tolerated dose of renin-angiotensin system (RAS) inhibitor.
Recommendation Grading
Overview
Title
Diabetes Management in Chronic Kidney Disease (CKD)
Authoring Organizations
American Diabetes Association
Kidney Disease Improving Global Outcomes
Publication Month/Year
October 3, 2022
Last Updated Month/Year
February 13, 2024
Supplemental Implementation Tools
Document Type
Consensus
Country of Publication
US
Document Objectives
People with diabetes and chronic kidney disease (CKD) are at high risk for kidney failure, atherosclerotic cardiovascular disease, heart failure, and premature mortality. Recent clinical trials support new approaches to treat diabetes and CKD. The 2022 American Diabetes Association (ADA) Standards of Medical Care in Diabetes and the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease each provide evidence-based recommendations for management. A joint group of ADA and KDIGO representatives reviewed and developed a series of consensus statements to guide clinical care from the ADA and KDIGO guidelines. The published guidelines are aligned in the areas of CKD screening and diagnosis, glycemia monitoring, lifestyle therapies, treatment goals, and pharmacologic management. Recommendations include comprehensive care in which pharmacotherapy that is proven to improve kidney and cardiovascular outcomes is layered on a foundation of healthy lifestyle. Consensus statements provide specific guidance on use of renin-angiotensin system inhibitors, metformin, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist. These areas of consensus provide clear direction for implementation of care to improve clinical outcomes of people with diabetes and CKD.
Target Patient Population
People with diabetes and CKD
Target Provider Population
Endocrinologists, nephrologists, internists, primary care and other allied providers
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient
Intended Users
Diabetes educator, nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management, Prevention
Diseases/Conditions (MeSH)
D003920 - Diabetes Mellitus, D007676 - Kidney Failure, Chronic, D007674 - Kidney Diseases, D012080 - Chronic Kidney Disease-Mineral and Bone Disorder
Keywords
diabetes, chronic kidney disease, CKD, KDIGO, ADA
Source Citation
De Boer IH, Khunti K, Sadusky T, Tuttle KR, Neumiller JJ, Rhee CM, Rosas SE, Rossing P, Bakris G. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022 Oct 3:dci220027. doi: 10.2337/dci22-0027. Epub ahead of print. PMID: 36189689.