Management of Chronic Kidney Disease
For patients with CKD, especially those with diabetes and hypertension, immediately initiate SGLT2 inhibitors (when eGFR ≥20 mL/min/1.73 m²) and ACE inhibitors or ARBs (titrated to maximum tolerated dose), target blood pressure <130/80 mmHg, and optimize glycemic control to HbA1c 6.5-8.0% based on individual hypoglycemia risk. 1, 2
Screening and Monitoring
Screen annually with spot urine albumin-to-creatinine ratio (UACR) and estimated GFR in all patients with type 2 diabetes regardless of duration, and in type 1 diabetes patients with disease duration ≥5 years 1
Monitor frequency varies by CKD stage: 1-4 times per year based on GFR category and albuminuria level, with more frequent monitoring (every 1-3 months) for patients at highest risk (GFR <30 mL/min/1.73 m² or severely elevated albuminuria) 1
Confirm albuminuria ≥30 mg/g on a random urine sample with a subsequent early morning sample before initiating treatment 1
Core Pharmacologic Strategy
SGLT2 Inhibitors (First-Line Kidney Protection)
Start SGLT2 inhibitors 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 2, 3
Dapagliflozin 10 mg daily is the preferred choice at eGFR levels down to 25 mL/min/1.73 m² 3
Reduce insulin doses by 10-20% when initiating SGLT2 inhibitors to mitigate hypoglycemia risk 3
Monitor for euglycemic ketoacidosis, especially during acute illness; counsel patients to maintain at least low-dose insulin and consider pausing SGLT2 inhibitors during periods of acute stress 3
Renin-Angiotensin System Blockade
For patients with moderately increased albuminuria (UACR 30-299 mg/g): Use either an ACE inhibitor or ARB 1
For patients with severely increased albuminuria (UACR ≥300 mg/g): Strongly recommend ACE inhibitor or ARB, titrated to the highest tolerated dose 1, 2
Specific dosing for diabetic nephropathy: Losartan is indicated for diabetic nephropathy with elevated serum creatinine and proteinuria (UACR ≥300 mg/g) in patients with type 2 diabetes and hypertension history, as it reduces progression to doubling of serum creatinine or end-stage renal disease 4
Monitor serum creatinine and potassium within 2-4 weeks after starting or increasing dose of ACE inhibitors or ARBs 2
Never combine ACE inhibitors with ARBs, as this increases harm despite theoretical benefits 2
Blood Pressure Management
Target BP <130/80 mmHg for all patients with diabetes and CKD to reduce cardiovascular mortality and slow CKD progression 1, 2
**For patients without albuminuria (UACR <30 mg/g):** Treat if office BP consistently >140/90 mmHg, maintaining BP ≤140/90 mmHg 1
For patients with albuminuria (UACR ≥30 mg/g): Treat if office BP consistently >130/80 mmHg, maintaining BP ≤130/80 mmHg 1
Check for postural hypotension regularly when treating CKD patients with BP-lowering drugs, especially in elderly patients 1
Add additional antihypertensive agents (amlodipine, chlorthalidone) as needed beyond RAS blockers to achieve target 2
Glycemic Control
Target HbA1c between 6.5-8.0%, individualized based on hypoglycemia risk, life expectancy, comorbidities, and patient preferences 2
For patients with CKD Stage 3b or higher: Target HbA1c 7.0-8.0% due to multiple comorbidities and high hypoglycemia risk 3
Check HbA1c every 3 months when therapy changes or targets are not met, and at least twice yearly in stable patients 2, 3
Metformin may be used when eGFR ≥30 mL/min/1.73 m² in combination with SGLT2 inhibitors 5
Optimize insulin regimens by increasing total daily dose by 2 units every 3 days while targeting fasting plasma glucose 80-130 mg/dL, with frequent glucose monitoring (at least 4 times daily initially) 3
Cardiovascular Risk Reduction
Initiate high-intensity statin therapy (atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily) immediately for all patients with diabetes and CKD, regardless of baseline LDL-cholesterol 2, 3
Cardiovascular events are more likely than progression to end-stage renal disease in CKD patients, so ensure level of care for ischemic heart disease is not prejudiced by CKD 2
Lifestyle Interventions
Restrict dietary protein to 0.8 g/kg/day for patients with diabetes and CKD not on dialysis to slow CKD progression 2, 3
Limit sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day) for blood pressure control 2, 3
Recommend moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 2, 3
Monitoring and Follow-Up
Reassess every 3-6 months: All cardiovascular and metabolic risk factors, kidney function (eGFR and UACR), electrolytes, and adjust medications as CKD progresses 2
Define CKD progression as decline in GFR category with ≥25% drop in eGFR from baseline, or rapid progression as sustained decline of ≥5 mL/min/1.73 m²/year 1
When CKD progression is identified, review current management and intensify interventions 1
Referral to Nephrology
Consider earlier referral for complex cases requiring multidisciplinary management involving nephrologists, endocrinologists, cardiologists, and dietitians 2
Refer based on GFR and albuminuria: Patients with GFR <30 mL/min/1.73 m² or severely elevated albuminuria warrant nephrology consultation 1
Critical Safety Considerations
Educate patients on genital mycotic infection risk (6% incidence with SGLT2 inhibitors) 3
Counsel to discontinue SGLT2 inhibitor and seek immediate care if signs of ketoacidosis develop (nausea, vomiting, abdominal pain, fatigue) even with normal glucose levels 3
Advise to hold ACE inhibitor or ARB during volume depletion (severe diarrhea, vomiting) but contact healthcare provider rather than stopping medications independently 5
Hyperkalemia associated with ACE inhibitor or ARB can often be managed without stopping these essential medications 5
Counsel on hypoglycemia symptoms, which may be blunted in CKD and with chronic poor control; prescribe glucagon for emergency use 3