What are the recommendations for diabetes (Dm) management in patients with Chronic Kidney Disease (CKD)?

Diabetes Management in Chronic Kidney Disease

For patients with diabetes and chronic kidney disease (CKD), treatment should follow a comprehensive strategy that includes metformin, SGLT2 inhibitors, and other evidence-based medications tailored to kidney function, along with lifestyle modifications to reduce risks of kidney disease progression and cardiovascular disease. 1

Screening and Diagnosis

• Annual screening for CKD should begin at diagnosis for type 2 diabetes (T2D) and 5 years after diagnosis for type 1 diabetes (T1D) 1
• Screening should include both spot urine albumin-to-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) 1
• CKD is diagnosed with persistent (≥3 months) eGFR <60 ml/min/1.73 m², ACR ≥30 mg/g, or other markers of kidney damage 1

Comprehensive Management Approach

Glycemic Control

• Individualized HbA1c targets ranging from <6.5% to <8.0% are recommended based on patient factors 1
• HbA1c remains the primary monitoring tool for glycemic control in CKD patients 1
• Continuous glucose monitoring (CGM) may be beneficial, especially when HbA1c is unreliable due to advanced CKD 1

Pharmacologic Management for T2D

First-line therapy:

• Metformin is recommended for patients with T2D, CKD, and eGFR ≥30 ml/min/1.73 m² 1

  • Reduce dose to 1000 mg daily when eGFR is 30-44 ml/min/1.73 m² 1
  • Consider dose reduction in some patients with eGFR 45-59 ml/min/1.73 m² at high risk of lactic acidosis 1
  • Discontinue when eGFR falls below 30 ml/min/1.73 m² 1

• SGLT2 inhibitors are recommended for patients with T2D, CKD, and eGFR ≥20 ml/min/1.73 m² regardless of baseline HbA1c or need for additional glucose lowering 1

  • Can be continued at lower eGFR levels once initiated, unless not tolerated or kidney replacement therapy is started 1
  • Should be temporarily withheld during prolonged fasting, surgery, or critical illness 1

Additional therapy as needed:

• GLP-1 receptor agonists with proven cardiovascular benefit are recommended for patients who don't meet glycemic targets with metformin and SGLT2i or cannot use these medications 1

• Nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) are recommended for patients with T2D, eGFR ≥25 ml/min/1.73 m², normal serum potassium, and albuminuria (ACR ≥30 mg/g) 1

  • Can be added to RAS inhibitor and SGLT2i therapy 1

Blood Pressure Management

• ACE inhibitors (ACEi) or angiotensin receptor blockers (ARB) are recommended for patients with diabetes, hypertension, and albuminuria 1
  • Should be titrated to the maximum tolerated dose 1
  • Continue even when eGFR falls below 30 ml/min/1.73 m² unless there are specific contraindications 1
  • Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1

Lipid Management

• Statin therapy is recommended for all patients with diabetes and CKD 1
  • Moderate intensity for primary prevention of atherosclerotic cardiovascular disease (ASCVD) 1
  • High intensity for patients with known ASCVD or multiple risk factors 1

Lifestyle Interventions

• Nutrition: Individualized 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

  • Maintain protein intake of 0.8 g/kg/day for CKD patients not on dialysis 1
  • Increase to 1.0-1.2 g/kg/day for patients on dialysis 1
  • Sodium intake should be <2 g per day 1

• Physical activity: At least 150 minutes per week of moderate-intensity physical activity, compatible with cardiovascular and physical tolerance 1

  • Avoid sedentary behavior 1
  • Consider age, comorbidities, and fall risk when recommending activity type and intensity 1

• Weight management: Consider weight loss for patients with obesity, diabetes, and CKD, particularly with eGFR ≥30 ml/min/1.73 m² 1

• Smoking cessation: All patients with diabetes and CKD who use tobacco should be advised to quit 1

Special Considerations

• Hypoglycemia risk increases with declining kidney function, particularly with insulin and sulfonylureas 2, 3
• Most oral antidiabetic agents require dose adjustments or are contraindicated in advanced CKD 3, 4
• Multidisciplinary care involving nephrology referral is beneficial when patients progress to stage 3 CKD or beyond 5

Monitoring

• Monitor kidney function at least annually when eGFR ≥60 ml/min/1.73 m² 1
• Increase monitoring to every 3-6 months when eGFR <60 ml/min/1.73 m² 1
• The initial reversible decrease in eGFR with SGLT2i initiation is generally not a reason to discontinue therapy 1