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

Treatment for Chronic Kidney Disease with Hypertension and Diabetes

Start an SGLT2 inhibitor immediately when eGFR ≥20 mL/min/1.73 m² regardless of glycemic control, combine with an ACE inhibitor or ARB (plus diuretic) for blood pressure control targeting <130/80 mmHg, and add statin therapy for cardiovascular protection. 1

Immediate Pharmacologic Interventions

First-Line Therapy: SGLT2 Inhibitors

• Initiate SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) as soon as CKD is diagnosed if eGFR ≥20 mL/min/1.73 m², even before optimizing glucose control. 1
• These agents provide kidney protection independent of glucose-lowering effects, reducing progression to end-stage renal disease by 39-40% and cardiovascular mortality. 2
• The renal benefits are as great or greater in patients with established CKD at baseline. 2

Blood Pressure Management

• Start ACE inhibitor or ARB in all patients with diabetes, hypertension, AND albuminuria, titrating to the highest tolerated dose. 2, 1
• Add a diuretic as second agent—most patients require combination therapy to achieve blood pressure targets. 2
• Target blood pressure <130/80 mmHg to reduce cardiovascular mortality and slow CKD progression. 2, 1
• Monitor serum creatinine and potassium within 2-4 weeks after starting or increasing ACE inhibitor/ARB doses. 1

Critical Pitfall: Never combine ACE inhibitors with ARBs—this increases adverse events (hyperkalemia, acute kidney injury) without additional benefit. 2, 1

Cardiovascular Risk Reduction

• Initiate statin therapy immediately in all patients with diabetes and CKD, regardless of baseline lipid levels or CKD stage. 1, 3
• High-intensity statins reduce cardiovascular events and mortality, which are more likely than progression to end-stage renal disease in this population. 1, 3

Glycemic Control Strategy

• Target HbA1c between 6.5-8.0%, individualized based on hypoglycemia risk, life expectancy, and comorbidities. 1
• Intensive glucose control (HbA1c ~7%) delays onset and progression of albuminuria and reduces eGFR decline. 1
• Check HbA1c every 3 months when therapy changes or targets are not met, and at least twice yearly in stable patients. 2, 1
• GLP-1 receptor agonists (liraglutide, semaglutide) provide additional renal protection, reducing new or worsening nephropathy by 22-36%. 2

Monitoring Protocol

Frequency Based on CKD Stage

• Monitor eGFR and urine albumin-to-creatinine ratio 1-4 times per year depending on CKD stage and albuminuria severity. 2, 1
• Yellow zone (mild CKD): once yearly monitoring. 2
• Deep red zone (advanced CKD with heavy albuminuria): every 1-3 months. 2

Regular Reassessment

• Reassess every 3-6 months: cardiovascular risk factors, kidney function, electrolytes (especially potassium), and medication adjustments. 2, 1
• Screen for acute kidney injury at each visit—all CKD patients are at increased risk. 1

Lifestyle Modifications

• Restrict sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day). 1, 4
• Limit protein intake to 0.8 g/kg/day for patients not on dialysis. 1, 4
• Recommend moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance. 1
• Smoking cessation is mandatory. 2

Nephrology Referral Criteria

Refer immediately when:

• eGFR <30 mL/min/1.73 m² (CKD stages 4-5). 4
• Urine albumin-to-creatinine ratio ≥300 mg/g despite treatment. 4
• Rapid eGFR decline (>5 mL/min/1.73 m² per year). 4
• Resistant hypertension despite multiple agents. 4
• Uncertainty about kidney disease etiology. 4

Comprehensive Complication Management

Screening for Diabetes Complications

• Annual comprehensive foot examination with monofilament testing and evaluation of pedal pulses—risk of ulcers and amputations is high. 2
• Regular screening for diabetic retinopathy. 2
• Visual foot inspection at every healthcare visit. 2

Multidisciplinary Team Approach

• Coordinate care involving nephrologists, endocrinologists, cardiologists, and dietitians for complex cases. 2, 1
• Provide structured patient education to promote self-management and shared decision-making. 2
• Avoid therapeutic inertia—most patients have high residual risks despite treatment and require multiple interventions. 2

Medication Safety

• Avoid nephrotoxins: NSAIDs, aminoglycosides, contrast agents, and proton pump inhibitors when possible. 5
• Adjust dosing for renally cleared medications based on eGFR. 5
• Review all medications at each visit for potential nephrotoxicity or need for dose adjustment. 5