What is the recommended management strategy for a patient with chronic kidney disease (CKD), hypertension, and diabetes type II, according to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines?

Drug Management in CKD with Hypertension and Type 2 Diabetes per KDIGO Guidelines

Start with an SGLT2 inhibitor immediately when eGFR ≥20 mL/min/1.73 m² regardless of glucose levels, add metformin if eGFR ≥30 mL/min/1.73 m², and initiate an ACE inhibitor or ARB titrated to maximum tolerated dose if albuminuria is present. 1, 2

First-Line Pharmacologic Strategy

SGLT2 Inhibitors (Priority #1)

• Initiate an SGLT2 inhibitor immediately when eGFR ≥20 mL/min/1.73 m², independent of glycemic control status. 2
• SGLT2 inhibitors provide kidney protection, cardiovascular benefits, and reduce heart failure hospitalizations even without glucose-lowering effects. 2
• Continue SGLT2 inhibitors until dialysis or transplantation is initiated, as kidney and cardiovascular benefits persist at lower eGFR levels. 2
• Before starting, assess hypoglycemia risk, particularly if the patient is on insulin or sulfonylureas, and consider dose reduction of these agents. 2

Metformin (Priority #2)

• Add metformin when eGFR ≥30 mL/min/1.73 m² for additional glycemic control. 1, 2
• Reduce metformin dose to 1000 mg daily when eGFR is 30-44 mL/min/1.73 m². 2
• Discontinue metformin when eGFR falls below 30 mL/min/1.73 m² due to lactic acidosis risk. 2

Hypertension Management with RAS Blockade

ACE Inhibitor or ARB Initiation

• Initiate an ACE inhibitor or ARB in all patients with diabetes, hypertension, AND albuminuria. 1, 2
• Titrate to the highest approved dose that is tolerated. 1
• For patients with albuminuria but normal blood pressure, treatment with an ACE inhibitor or ARB may still be considered. 1

Monitoring Protocol for RAS Blockade

• Monitor serum creatinine and potassium within 2-4 weeks after starting or increasing the dose. 1, 2
• Continue therapy unless creatinine rises >30% within 4 weeks—this degree of increase warrants evaluation for acute kidney injury, volume depletion, renal artery stenosis, or concomitant nephrotoxic medications (NSAIDs, diuretics). 1, 2
• For hyperkalemia, do not immediately discontinue the ACE inhibitor or ARB—first attempt management through dietary potassium restriction, diuretics, sodium bicarbonate, or GI cation exchangers. 1, 2
• Reduce dose or discontinue only as a last resort for uncontrolled hyperkalemia despite medical management or symptomatic hypotension. 1
• Advise contraception in women receiving ACE inhibitor or ARB therapy and discontinue these agents in women considering pregnancy or who become pregnant. 1

Additional Glucose-Lowering Therapies

GLP-1 Receptor Agonists

• Add a long-acting GLP-1 receptor agonist if glycemic targets are not met with metformin and SGLT2 inhibitors, or if these agents cannot be used. 1, 2

Advanced Kidney Protection

Nonsteroidal Mineralocorticoid Receptor Antagonist

• Consider adding finerenone for patients with type 2 diabetes who have persistent albuminuria ≥30 mg/g (≥3 mg/mmol) despite first-line therapy and normal potassium levels. 2

Cardiovascular Risk Reduction

Statin Therapy

• Initiate statin therapy in all patients with type 1 or type 2 diabetes and CKD, regardless of baseline lipid levels. 2, 3

Antiplatelet Therapy

• Use aspirin for secondary prevention in patients with established cardiovascular disease. 3
• Consider aspirin for primary prevention among high-risk individuals, balancing bleeding risk. 3

Glycemic Monitoring and Targets

HbA1c Monitoring

• Use HbA1c to monitor glycemic control. 1, 2
• Check every 3 months when therapy changes or targets are not met, and at least twice yearly in stable patients. 2

HbA1c Target Range

• Target HbA1c between <6.5% and <8.0%, individualized based on hypoglycemia risk, life expectancy, comorbidities, and patient preferences. 1, 2

Lifestyle Interventions

Dietary Modifications

• Limit protein intake to 0.8 g/kg/day for patients with diabetes and CKD not on dialysis. 1, 2
• Restrict sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day). 1, 2
• Consume a diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts; lower in processed meats, refined carbohydrates, and sweetened beverages. 1

Physical Activity

• Advise moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance. 1, 2

Tobacco Cessation

• Strongly recommend tobacco cessation for all patients who use tobacco products. 1, 2

Common Pitfalls and Caveats

• Do not withhold SGLT2 inhibitors based on glucose levels alone—their primary benefit in CKD is kidney and cardiovascular protection, not glycemic control. 2
• Do not immediately stop ACE inhibitors or ARBs for mild creatinine elevation (<30%) or hyperkalemia—attempt medical management first. 1, 2
• Do not continue metformin below eGFR 30 mL/min/1.73 m² due to lactic acidosis risk. 2
• Reassess all cardiovascular and metabolic risk factors every 3-6 months, monitoring kidney function, electrolytes, and adjusting medications as CKD progresses. 3