What are the diagnosis and treatment approaches for an older adult with diabetes, hypertension, and chronic kidney disease (CKD)?

Diagnosis and Treatment of CKD in Older Adults with Diabetes and Hypertension

For an older adult with diabetes, hypertension, and CKD, diagnose by measuring eGFR and urine albumin excretion, then treat with an ACE inhibitor or ARB targeting blood pressure ≤130/80 mmHg if albuminuria ≥30 mg/24h, combined with an SGLT2 inhibitor and statin therapy to reduce cardiovascular mortality and slow CKD progression. 1, 2

Diagnostic Approach

Initial Screening and Diagnosis

• Measure both eGFR and urine albumin excretion using serum creatinine-based equations and albumin-to-creatinine ratio (ACR) on a random urine sample 1, 3
• Confirm albuminuria ≥30 mg/g with a subsequent early morning urine sample if initial screening is positive 1
• CKD is defined as eGFR <60 mL/min/1.73 m² or albuminuria ≥30 mg/24h (or equivalent) persisting for >3 months 1, 3
• Stage CKD using GFR categories: G1 (≥90), G2 (60-89), G3a (45-59), G3b (30-44), G4 (15-29), G5 (<15 mL/min/1.73 m²) 1

Monitoring for Progression

• Assess GFR and albuminuria at least annually in all CKD patients, more frequently in those at higher risk of progression 1
• Define progression as: decline in GFR category with ≥25% drop in eGFR from baseline, or rapid progression defined as sustained decline ≥5 mL/min/1.73 m²/year 1
• Recognize small fluctuations in GFR are common and not necessarily indicative of true progression versus acute kidney injury 1

Risk Stratification

• Identify factors associated with CKD progression: cause of CKD, level of GFR, level of albuminuria, age, sex, race/ethnicity, elevated BP, hyperglycemia, dyslipidemia, smoking, obesity, cardiovascular disease history, and nephrotoxic agent exposure 1

Treatment Strategy

Blood Pressure Management

Target BP ≤130/80 mmHg for patients with albuminuria ≥30 mg/24h 1, 2

• For patients with albuminuria <30 mg/24h, target BP ≤140/90 mmHg 1
• The American College of Cardiology recommends systolic BP <120 mmHg when tolerated, based on SPRINT trial data showing cardiovascular and mortality benefits in CKD patients 2, 4

First-line antihypertensive: ACE inhibitor or ARB 1, 2, 5

• Use ACE-I or ARB in diabetic adults with albuminuria 30-300 mg/24h (moderate strength recommendation) 1
• Use ACE-I or ARB in both diabetic and non-diabetic adults with albuminuria >300 mg/24h (strong recommendation) 1
• If ACE inhibitor not tolerated, switch to ARB 2, 6
• Never combine ACE-I with ARB due to increased hyperkalemia and hypotension without additional benefit 1, 4

Monitoring ACE-I/ARB therapy:

• Check renal function and serum potassium within 1-2 weeks of initiation, with each dose increase, and at least yearly 2
• A 10-25% increase in serum creatinine is acceptable due to hemodynamic effects 2
• Creatinine increases >30% warrant investigation for volume depletion, nephrotoxic agents, or renovascular disease 2
• Inquire about postural dizziness and check for orthostatic hypotension regularly 1

Additional antihypertensive agents:

• Add thiazide-like diuretic or dihydropyridine calcium channel blocker as second-line therapy if BP remains uncontrolled 2, 6
• Tailor regimens in elderly patients with gradual escalation and close attention to adverse events including electrolyte disorders, acute kidney function deterioration, and orthostatic hypotension 1

Glucose Management in Diabetes with CKD

SGLT2 inhibitors are recommended regardless of HbA1c for patients with diabetes and CKD to reduce progression and cardiovascular events 1

• Canagliflozin and dapagliflozin have documented kidney and cardiovascular benefits 1
• For eGFR <20 mL/min/1.73 m², prefer GLP-1 RA (dulaglutide, semaglutide, or liraglutide) but continue SGLT2 inhibitor if already established 1

Metformin dosing adjustments:

• Continue metformin but reduce dose for eGFR <45 mL/min/1.73 m² 1
• Do not initiate or discontinue metformin for eGFR <30 mL/min/1.73 m² or dialysis 1

Glycemic target:

• Aim for HbA1c <7.0% using shared decision-making and considering individual patient factors 1, 7

Lipid Management

All adults aged 50+ years with CKD should receive statin therapy or statin/ezetimibe combination 1

• Statin therapy reduces atherosclerotic events in CKD patients 1
• Target LDL cholesterol <100 mg/dL, possibly <70 mg/dL 7
• Consider dose reduction of statins for eGFR <60 mL/min/1.73 m² due to toxicity concerns 1
• Follow-up lipid measurement is not required for most patients but can assess compliance 1

Mineralocorticoid Receptor Antagonist

Consider finerenone (nonsteroidal MRA) to reduce CKD progression and cardiovascular events 1

• Finerenone has lower rates of hyperkalemia compared to steroidal MRAs (spironolactone, eplerenone) 1

Nephrotoxin Avoidance

Avoid NSAIDs entirely in CKD patients as they cause acute kidney injury, worsen hypertension, cause fluid retention, and precipitate hyperkalemia 8, 3

• Use acetaminophen for pain and fever instead 8
• Review all medications for appropriate renal dosing 8, 3

Monitoring for CKD Complications

Monitor for and treat:

• Hyperkalemia (especially with ACE-I/ARB therapy) 1, 8, 3
• Metabolic acidosis 3
• Hyperphosphatemia 3
• Vitamin D deficiency 3
• Secondary hyperparathyroidism 3
• Anemia 3

Referral to Nephrology

Refer promptly to nephrology for:

• eGFR <30 mL/min/1.73 m² (stages 4-5) 3, 9
• Albuminuria ≥300 mg per 24 hours 3
• Rapid decline in eGFR 3
• All patients with CKD stages 4-5 should be referred 9

Critical Pitfalls to Avoid

• Do not combine ACE-I with ARB as this increases adverse effects without benefit 1, 4
• Do not use NSAIDs in CKD patients 8, 3
• Do not overlook cardiovascular risk reduction as most CKD patients die from cardiovascular complications rather than progressing to ESRD 4
• Do not fail to adjust medication doses for renal function 8, 3
• Do not ignore orthostatic hypotension risk in elderly patients on multiple antihypertensives 1, 2