What is the best management approach for a patient with Chronic Kidney Disease (CKD), hypertension, and diabetes?

Management of Chronic Kidney Disease with Hypertension and Diabetes

For patients with CKD, diabetes, and hypertension, immediately initiate an SGLT2 inhibitor (when eGFR ≥20 mL/min/1.73 m²) and an ACE inhibitor or ARB (if albuminuria is present), while targeting blood pressure <130/80 mmHg and HbA1c between 6.5-8.0%. 1

Initial Assessment and Monitoring

• Screen annually with spot urinary albumin-to-creatinine ratio and estimated GFR in all patients with type 2 diabetes regardless of duration, and in type 1 diabetes patients with disease duration ≥5 years 2
• Monitor frequency should be 1-4 times per year based on CKD stage: green (normal) = annually, yellow = once yearly, orange = twice yearly, red = three times yearly, dark red = four times yearly 2
• Check HbA1c every 3 months when therapy changes or targets are not met, and at least twice yearly in stable patients 1

Core Pharmacologic Strategy

SGLT2 Inhibitors (First Priority)

• Start immediately when eGFR ≥20 mL/min/1.73 m², regardless of glycemic control status, as this provides kidney protection, cardiovascular benefits, and reduces heart failure hospitalizations independent of glucose-lowering effects 1
• Continue until dialysis or transplantation is initiated, even as eGFR declines, since kidney and cardiovascular benefits persist at lower eGFR levels 1
• Reduce insulin or sulfonylurea doses when starting SGLT2 inhibitors to prevent hypoglycemia 1

RAS Inhibition (ACE Inhibitor or ARB)

• Initiate in all patients with diabetes, hypertension, AND albuminuria (albumin-to-creatinine ratio >30 mg/g), titrating to the highest tolerated dose 2, 1
• Monitor serum creatinine and potassium within 2-4 weeks after starting or increasing dose 2, 1
• Continue therapy unless creatinine rises >30% within 4 weeks—this degree of increase warrants evaluation for acute kidney injury, volume depletion, or renal artery stenosis 1
• Never combine ACE inhibitors with ARBs, as this is harmful in patients with diabetes and CKD 2

Metformin

• Add metformin when eGFR ≥30 mL/min/1.73 m² for additional glycemic control 1
• Reduce dose to 1000 mg daily when eGFR is 30-44 mL/min/1.73 m² 1
• Discontinue when eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk 1
• Temporarily discontinue before iodinated contrast imaging in patients with eGFR 30-60 mL/min/1.73 m² 2

Blood Pressure Management

Target Blood Pressure

• Target <130/80 mmHg for all patients with diabetes and CKD to reduce cardiovascular mortality and slow CKD progression 2
• Consider lower targets (e.g., <130/80 mmHg) in patients with severely elevated albuminuria (≥300 mg/g creatinine) 2
• For patients with albuminuria <30 mg/24 hours, target ≤140/90 mmHg 2
• For patients with albuminuria ≥30 mg/24 hours, target ≤130/80 mmHg 2

Managing Hyperkalemia with RAS Inhibitors

• Do not immediately discontinue ACE inhibitors or ARBs for hyperkalemia—first attempt to manage potassium through dietary modification, diuretics, sodium bicarbonate, or GI cation exchangers 1
• Reduce dose or withdraw only if symptomatic hypotension or uncontrolled hyperkalemia persists despite these measures 2

Glycemic Control

Target HbA1c

• Target HbA1c between 6.5-8.0%, individualized based on hypoglycemia risk, life expectancy, comorbidities, and patient preferences 1
• Intensive glucose control (HbA1c ~7%) delays onset and progression of albuminuria and reduces eGFR decline 2
• Less intensive targets may be appropriate in patients with prevalent CKD and substantial comorbidity, given the 2+ year lag time for benefits and increased hypoglycemia risk 2

Additional Glucose-Lowering Agents

• Add a GLP-1 receptor agonist if glycemic targets are not met with metformin and SGLT2 inhibitors, or if these agents cannot be used 1
• Consider finerenone (nonsteroidal MRA) for patients with type 2 diabetes who have persistent albuminuria ≥30 mg/g despite first-line therapy and normal potassium levels 1

Cardiovascular Risk Reduction

• Initiate statin therapy in all patients with type 1 or type 2 diabetes and CKD, regardless of baseline lipid levels, to reduce cardiovascular events and mortality 3, 1
• Ensure level of care for ischemic heart disease is not prejudiced by CKD, as patients with CKD are more likely to have cardiovascular events than progress to end-stage renal disease 2

Lifestyle Interventions

• Limit protein intake to 0.8 g/kg/day for patients with diabetes and CKD not on dialysis 1
• Restrict sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day) 2, 1
• Advise moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 1
• Strongly recommend tobacco cessation for all patients who use tobacco products 2, 1
• Target healthy body mass index of 20-25 kg/m² 2

Monitoring and Follow-Up

Hemoglobin Monitoring

• Monitor hemoglobin weekly after initiating or adjusting therapy until stable, then at least monthly 2
• Evaluate iron status before and during treatment, administering supplemental iron when serum ferritin <100 mcg/L or transferrin saturation <20% 4

Kidney Function Monitoring

• Reassess every 3-6 months all cardiovascular and metabolic risk factors, monitoring kidney function, electrolytes, and adjusting medications as CKD progresses 3
• Monitor for acute kidney injury, as all people with CKD are at increased risk 2

Referral to Nephrology

• Refer when eGFR <30 mL/min/1.73 m², severe albuminuria is present, or acute kidney injury occurs 5
• Consider earlier referral for complex cases requiring multidisciplinary management involving nephrologists, endocrinologists, cardiologists, and dietitians 2

Common Pitfalls to Avoid

• Avoid NSAIDs, as they are nephrotoxic and should be avoided in CKD patients 5
• Never combine ACE inhibitors with ARBs, despite theoretical benefits, as this increases harm 2
• Do not target hemoglobin >11 g/dL with ESAs in CKD patients, as this increases risks for death, serious cardiovascular reactions, and stroke 4
• Do not overlook cardiovascular disease management, as cardiovascular events are more likely than progression to end-stage renal disease 2