What are the American Diabetes Association (ADA) recommendations for primary prevention of Chronic Kidney Disease (CKD) in patients with Diabetes Mellitus (DM) without Hypertension (HT)?

ADA Recommendations for Primary Prevention of CKD in Diabetic Patients Without Hypertension

Core Recommendation

The American Diabetes Association explicitly states that the only proven primary prevention interventions for CKD in patients with diabetes without hypertension are glycemic control targeting HbA1c of 7% and blood pressure management, with no recommendation for renin-angiotensin-aldosterone system inhibitors or other medications solely for CKD prevention in the absence of hypertension or albuminuria. 1

Glycemic Control Strategy

Target HbA1c of 7% to prevent or delay progression of microvascular complications, including diabetic kidney disease. 1

• This target is based on strong evidence from landmark trials (DCCT, UKPDS) demonstrating reduced risk of microalbuminuria and retinopathy with intensive glycemic control 1
• The 2023 GRADE study found no unique renoprotective effects among liraglutide, sitagliptin, glimeperide, and insulin glargine for primary prevention in patients without existing kidney disease 1
• Do not target HbA1c below 7% in patients at risk of hypoglycemia 1
• Consider extending target above 7% (up to 8%) in patients with comorbidities or limited life expectancy 1

Blood Pressure Management (Even Without Hypertension Diagnosis)

Monitor blood pressure at every clinical contact, targeting <130/80 mmHg if cardiovascular risk is high (10-year ASCVD risk ≥15%), or <140/90 mmHg if cardiovascular risk is low 1

• Blood pressure control is critical even in normotensive patients to prevent CKD development 1
• Proper BP measurement techniques using standardized office measurements are essential 1

What NOT to Do

The ADA explicitly recommends AGAINST using ACE inhibitors or ARBs for primary prevention of CKD in normotensive patients with diabetes who do not have albuminuria. 1

• This is a Grade 1A recommendation from KDOQI guidelines 1
• There is no evidence that RAAS inhibitors prevent CKD development in the absence of hypertension or albuminuria 1
• The ADA does not recommend routine use of these medications solely for CKD prevention 1

Surveillance Requirements

Monitor both albuminuria and eGFR annually to enable timely diagnosis of CKD and detect early changes 1

• Annual screening allows for early detection when interventions become appropriate 1
• Once albuminuria develops (>30 mg/g), treatment strategies change significantly 1

Dietary Protein Recommendations

Maintain dietary protein intake at 0.8 g/kg body weight per day (the recommended daily allowance) 1

• Higher protein intake (>20% of daily calories or >1.3 g/kg/day) is associated with increased albuminuria and more rapid kidney function loss 1
• Do not reduce protein below 0.8 g/kg/day, as this does not alter glycemic control or prevent CKD development 1

Critical Clinical Pitfall

The most common error is prescribing ACE inhibitors or ARBs to normotensive diabetic patients without albuminuria under the mistaken belief this prevents CKD. This practice lacks evidence and is explicitly not recommended by the ADA 1. The focus should remain on achieving glycemic targets and monitoring for the development of hypertension or albuminuria, at which point treatment strategies appropriately escalate.