What are the guidelines for diabetes management in Chronic Kidney Disease (CKD) patients not on Hemodialysis (HD)?

Guidelines for Diabetes Management in CKD Patients Not on Hemodialysis

First-line therapy for diabetes management in CKD patients not on hemodialysis should include metformin and an SGLT2 inhibitor for patients with eGFR ≥30 ml/min per 1.73 m², with individualized HbA1c targets ranging from <6.5% to <8.0% based on hypoglycemia risk. 1

Glycemic Monitoring and Targets

Monitoring Recommendations

• Use HbA1c to monitor glycemic control, measuring twice yearly if stable or quarterly if target not met or after therapy changes 1
• Consider alternative monitoring methods when eGFR <30 ml/min/1.73 m² as HbA1c accuracy declines 1, 2:
  • Continuous glucose monitoring (CGM)
  • Self-monitoring of blood glucose (SMBG)
  • Glucose management indicator (GMI) derived from CGM data

Glycemic Targets

• HbA1c target should range from <6.5% to <8.0% based on individual factors 1
• Lower targets (<6.5% or <7.0%) may be appropriate when:
  • Using medications with low hypoglycemia risk
  • Patient has adequate CGM or SMBG monitoring
• Higher targets may be appropriate with:
  • History of severe hypoglycemia
  • Limited life expectancy
  • Advanced complications
  • Extensive comorbidities

Pharmacological Management Algorithm

First-Line Therapy

1. Metformin:

   • Recommended for eGFR ≥30 ml/min/1.73 m² 1
   • Dose adjustment: Reduce dose when eGFR <45 ml/min/1.73 m²
   • Discontinue when eGFR <30 ml/min/1.73 m² 1

2. SGLT2 inhibitor:

   • Recommended for eGFR ≥30 ml/min/1.73 m² 1
   • Benefits beyond glycemic control: Reduces cardiovascular events and slows CKD progression 2
   • Discontinue when eGFR <30 ml/min/1.73 m² 1

Additional Therapy (if glycemic targets not met)

1. GLP-1 receptor agonist (preferred) 1:

   • Long-acting formulations recommended
   • Provides cardiovascular benefits
   • Can be used across all stages of CKD

2. Other options (based on eGFR):

   • DPP-4 inhibitors (dose-adjusted for renal function)
   • Thiazolidinediones (TZDs)
   • Insulin (especially for eGFR <30 ml/min/1.73 m²)
   • Sulfonylureas (use with caution due to hypoglycemia risk)

Lifestyle Management

Dietary Recommendations

• Protein intake: 0.8 g protein/kg body weight/day for non-dialysis CKD patients 1, 2
• Sodium intake: <2 g sodium per day (<5 g sodium chloride) 1
• General diet: High in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts; lower in processed meats, refined carbohydrates, and sweetened beverages 1, 2

Physical Activity

• 150 minutes per week of moderate-intensity physical activity 1, 2
• Adjust intensity based on cardiovascular tolerance and fall risk
• Avoid sedentary behavior 1

Weight Management

• Weight loss recommended for patients with obesity, particularly if eGFR ≥30 ml/min per 1.73 m² 1

Special Considerations and Pitfalls

Monitoring Challenges

• HbA1c becomes less reliable as kidney function declines (eGFR <30 ml/min/1.73 m²) 1, 2, 3
• CGM metrics (time in range 70-180 mg/dL) may be better alternatives for glycemic assessment 1, 4, 3

Medication Adjustments

• Regular monitoring of kidney function is essential when using metformin and SGLT2 inhibitors
• Increased risk of hypoglycemia with insulin and sulfonylureas as kidney function declines 5
• Dose adjustments needed for many diabetes medications as CKD progresses

Multidisciplinary Approach

• Involve registered dietitians, diabetes educators, and other healthcare providers in nutritional care 1
• Consider cultural differences, food intolerances, resource variations, cooking skills, and cost when recommending dietary options 1

By following these evidence-based guidelines, clinicians can optimize diabetes management in CKD patients not on hemodialysis, potentially slowing disease progression and reducing cardiovascular complications.