Optimize Glycemic Control While Continuing Kerendia for Progressive Diabetic Kidney Disease
Your patient requires intensification of diabetes therapy to address the rising HbA1c while maintaining Kerendia, as the worsening kidney function (rising UACR and falling eGFR) indicates progressive diabetic kidney disease that demands both optimal glycemic control and continued cardiorenal protection.
Immediate Action: Intensify Diabetes Therapy
Add an SGLT2 inhibitor immediately if not already prescribed, as this is the highest priority intervention for a diabetic patient with progressive kidney disease, providing both glycemic control and direct kidney protection independent of glucose lowering 1, 2.
The rising HbA1c from 6.9% to 7.2% exceeds the ADA target of <7.0% for most patients, requiring therapeutic adjustment 3.
The discordance between fasting glucose (82 mg/dL) and HbA1c (7.2%) suggests postprandial hyperglycemia or glycemic variability, indicating inadequate overall glucose control despite acceptable fasting values 3.
Understanding the Clinical Context
Progressive kidney disease is the primary concern:
Rising UACR combined with falling eGFR represents the highest-risk trajectory for advanced CKD, with a hazard ratio of 15.15 (95% CI 12.43-18.46) for progression to advanced kidney disease 4.
This combination of worsening kidney parameters mandates twice-yearly monitoring of UACR and eGFR, as recommended for patients with UACR >300 mg/g or eGFR 30-60 mL/min/1.73 m² 3.
Long-term elevated UACR significantly increases risk of major adverse cardiac events (HR 1.648 for elevated-increasing trajectory) 5.
Specific Treatment Algorithm
Step 1: Add SGLT2 Inhibitor (if not contraindicated by eGFR <25 mL/min/1.73 m²)
SGLT2 inhibitors reduce CKD progression and cardiovascular events as first-line therapy, with a 30% reduction in composite kidney outcomes 1.
They provide a 29% reduction in cardiovascular death or heart failure hospitalization (HR 0.71,95% CI 0.55-0.92) 1.
SGLT2 inhibitors can be initiated down to eGFR ≥25 mL/min/1.73 m², and will improve both glycemic control and kidney outcomes 1.
Step 2: Continue Kerendia (Finerenone)
Do not discontinue Kerendia despite rising HbA1c, as finerenone provides independent cardiorenal protection beyond glycemic control 2, 6.
Finerenone reduces kidney disease progression by 18% (HR 0.82,95% CI 0.73-0.93) and cardiovascular events by 13% (HR 0.87,95% CI 0.76-0.98) 1, 6.
Early albuminuria reduction with finerenone mediates 84% of treatment effect on kidney outcomes 7.
Monitor serum potassium at 1 month, then periodically, as hyperkalemia risk increases with progressive kidney disease 1, 2.
Step 3: Consider Additional Glucose-Lowering Therapy
If SGLT2 inhibitor alone is insufficient, add a GLP-1 receptor agonist, which provides additional cardiovascular protection (HR 0.87 for MACE in LEADER trial) and glycemic control 3.
Avoid medications that worsen with declining kidney function (adjust doses of sulfonylureas, DPP-4 inhibitors, or insulin as needed based on current eGFR) 3.
Critical Monitoring Parameters
Kidney function surveillance:
Repeat UACR and eGFR within 1-3 months to assess trajectory 3.
Expect a transient 5-10% eGFR decline in first 2 weeks after starting SGLT2 inhibitor—this is hemodynamic and predicts better long-term kidney protection 1.
Consider nephrology referral if eGFR falls below 45 mL/min/1.73 m² for coordinated care, or urgently if eGFR drops below 30 mL/min/1.73 m² 3.
Glycemic monitoring:
Obtain continuous glucose monitoring or structured self-monitoring to identify postprandial hyperglycemia patterns 3.
Target HbA1c <7.0% while avoiding hypoglycemia, given the fasting glucose is already 82 mg/dL 3.
Potassium monitoring:
Check serum potassium at 1 month after any medication changes, then every 3-6 months 1, 2.
Withhold finerenone if potassium >5.5 mmol/L and restart at lower dose when potassium returns to ≤5.0 mmol/L 2.
Common Pitfalls to Avoid
Do not attribute rising HbA1c to finerenone—finerenone does not cause hyperglycemia and should be continued for cardiorenal protection 2, 6.
Do not delay SGLT2 inhibitor initiation due to concerns about eGFR decline—the initial dip is hemodynamic and beneficial long-term 1.
Do not focus solely on fasting glucose—the discordance with HbA1c indicates inadequate 24-hour glycemic control requiring comprehensive assessment 3.
Do not discontinue finerenone prematurely for hyperkalemia without attempting dose reduction and potassium management strategies 2.
Blood Pressure Optimization
Verify blood pressure is at target (<130/80 mm Hg for most patients with diabetes and CKD) 3.
Ensure maximum tolerated dose of ACE inhibitor or ARB is prescribed, as this is foundational therapy before finerenone 1, 2.
KDIGO recommends SBP <120 mm Hg for adults with type 2 diabetes and CKD if tolerated 3.