How can I slow the progression of my CKD stage 3b with type 1 diabetes and hypertension?

How to Retard CKD 3b Progression in Type 1 Diabetes

You need to add an SGLT2 inhibitor immediately to your current regimen, as this represents the single most important intervention you are currently missing to prevent dialysis. 1

Critical Missing Medication: SGLT2 Inhibitor

Add an SGLT2 inhibitor (canagliflozin, empagliflozin, or dapagliflozin) as your highest priority intervention. The evidence is compelling:

• SGLT2 inhibitors reduce the risk of kidney failure, dialysis, or renal death by 30-40% in patients with diabetic kidney disease, even when added to maximum ACE inhibitor/ARB therapy 1
• These benefits persist down to eGFR levels of 30 mL/min/1.73 m² (your CKD 3b range), independent of glucose-lowering effects 1
• In the CREDENCE trial specifically, canagliflozin reduced the primary endpoint (chronic dialysis ≥30 days, kidney transplantation, sustained eGFR <15, doubling of serum creatinine, ESRD, or death from ESRD) by 30% on top of background ACE inhibitor/ARB therapy in >99% of patients 1
• Cardiovascular death or heart failure hospitalization was reduced by 31%, providing dual kidney and heart protection 1

Optimize Your Current Blood Pressure Management

Target blood pressure <130/80 mmHg, potentially even lower given your CKD 3b with diabetes. 1

• You are already on maximum doses of perindopril (ACE inhibitor) and zanidip (calcium channel blocker), which is appropriate 1
• ACE inhibitors are the preferred first-line agent for type 1 diabetes with CKD, proven to reduce progression to ESRD 1
• Monitor your blood pressure closely; if not at target, you may need additional antihypertensive agents 1

Critical caveat: Monitor serum creatinine and potassium levels regularly when on ACE inhibitors, especially after adding SGLT2 inhibitors 1, 2

Consider Adding Finerenone (Non-Steroidal MRA)

Finerenone should be your next addition after SGLT2 inhibitor if albuminuria persists. 1, 3

• In the FIDELIO-DKD trial, finerenone reduced the composite kidney outcome (kidney failure, sustained ≥40% eGFR decrease, or renal death) by 18% when added to ACE inhibitor/ARB therapy 1
• In FIGARO-DKD, finerenone reduced end-stage kidney disease by 36% (HR 0.64) in patients with moderately elevated albuminuria 1
• Dosing: Start 10 mg once daily if your eGFR is 25-60 mL/min/1.73 m² (your CKD 3b range), increase to 20 mg after 1 month if potassium ≤4.8 mmol/L 1
• Hyperkalemia risk is real but manageable: only 1.2-2.3% discontinued due to hyperkalemia in trials, with no deaths related to hyperkalemia 1

Optimize Glycemic Control

Maintain HbA1c as close to 7% as safely possible without causing hypoglycemia. 1

• Your current insulin regimen (NovoRapid and Toujeo) is appropriate for type 1 diabetes 1
• Tight glycemic control reduces the risk and slows progression of diabetic kidney disease 1
• Monitor HbA1c every 3 months while adjusting therapy 1

Monitor Albuminuria as a Treatment Target

Request annual (or more frequent) urine albumin-to-creatinine ratio (UACR) testing to guide therapy intensity. 1, 2

• Reduction in urinary albumin excretion directly correlates with kidney protection and reduced cardiovascular risk 1
• The degree of albuminuria reduction predicts the effectiveness of your therapy 1
• If albuminuria increases despite optimal therapy, this signals need for treatment intensification 2

Mandatory Nephrologist Referral

You should already be under nephrology care given your CKD 3b (eGFR <45 mL/min/1.73 m²). 1

• Referral to a nephrologist when eGFR <30 mL/min/1.73 m² (stage 4 CKD) reduces cost, improves quality of care, and delays dialysis 1
• However, with CKD 3b and type 1 diabetes, earlier referral is appropriate for optimizing complex medication regimens and monitoring complications 1
• The nephrologist can help manage potential complications: anemia, secondary hyperparathyroidism, metabolic bone disease, resistant hypertension, and electrolyte disturbances 1

Continue Current Lipid Management

Your atorvastatin and ezetimibe combination is appropriate and should be continued. 1

• Cardiovascular disease is a major cause of mortality in diabetic kidney disease, making aggressive lipid management essential 1

Critical Pitfalls to Avoid

Never combine your ACE inhibitor (perindopril) with an ARB - this combination increases adverse events (hyperkalemia, acute kidney injury) without additional kidney or cardiovascular benefits 1

Do not reduce dietary protein below 0.8 g/kg/day - this does not alter glycemic control, cardiovascular risk, or GFR decline 1

The "Pillars of Therapy" Approach

The modern standard for preventing dialysis in diabetic kidney disease requires three medication classes working together: 3

1. Maximally dosed ACE inhibitor or ARB (you have this: perindopril at maximum dose) 3
2. SGLT2 inhibitor (you are missing this - add immediately) 3
3. Non-steroidal mineralocorticoid receptor antagonist/finerenone (consider adding after SGLT2 inhibitor) 3

These three classes provide complementary anti-inflammatory, anti-fibrotic, and hemodynamic effects with additive benefits on slowing disease progression 3