Diabetes Management in Chronic Kidney Disease (CKD)

Publication Date: October 3, 2022
Last Updated: January 31, 2023

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.

Overview

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Diabetes Management in Chronic Kidney Disease (CKD)

Authoring Organizations