Diabetes Management in Chronic Kidney Disease

Screening and Diagnosis

Annual screening for CKD should begin at diagnosis for type 2 diabetes and 5 years after diagnosis for type 1 diabetes, including spot urine albumin-to-creatinine ratio and estimated glomerular filtration rate 1
CKD is diagnosed with persistent eGFR <60 ml/min/1.73 m², albumin-to-creatinine ratio ≥30 mg/g, or other markers of kidney damage 1

Individualized HbA1c targets ranging from <6.5% to <8.0% are recommended based on patient factors, with HbA1c as the primary monitoring tool for glycemic control in CKD patients 3
Continuous glucose monitoring may be beneficial, especially when HbA1c is unreliable due to advanced CKD 4

Metformin is recommended for patients with T2D, CKD, and eGFR ≥30 ml/min/1.73 m², with dose reduction or discontinuation as eGFR declines 5, 6
SGLT2 inhibitors are recommended for patients with T2D, CKD, and eGFR ≥20 ml/min/1.73 m², regardless of baseline HbA1c or need for additional glucose lowering 5, 7
GLP-1 receptor agonists with proven cardiovascular benefit are recommended for patients who don't meet glycemic targets with metformin and SGLT2i or cannot use these medications 1, 5
Nonsteroidal mineralocorticoid receptor antagonists are recommended for patients with T2D, eGFR ≥25 ml/min/1.73 m², normal serum potassium, and albuminuria 1, 7

ACE inhibitors or angiotensin receptor blockers are recommended for patients with diabetes, hypertension, and albuminuria, with titration to the maximum tolerated dose 1, 2, 8
These medications should be continued even when eGFR falls below 30 ml/min/1.73 m² unless there are specific contraindications 7

Statin therapy is recommended for all patients with diabetes and CKD, with moderate intensity for primary prevention of atherosclerotic cardiovascular disease and high intensity for patients with known ASCVD or multiple risk factors 1, 6

A individualized diet high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts, and lower in processed meats, refined carbohydrates, and sweetened beverages is recommended 3, 4
Protein intake should be 0.8 g/kg/day for CKD patients not on dialysis and 1.0-1.2 g/kg/day for patients on dialysis, with sodium intake <2 g per day 3, 4
At least 150 minutes per week of moderate-intensity physical activity is recommended, compatible with cardiovascular and physical tolerance, with avoidance of sedentary behavior 3, 4
Weight loss should be considered for patients with obesity, diabetes, and CKD, particularly with eGFR ≥30 ml/min/1.73 m² 4
Smoking cessation is recommended for all patients with diabetes and CKD who use tobacco 3

Kidney function should be monitored at least annually when eGFR ≥60 ml/min/1.73 m² and every 3-6 months when eGFR <60 ml/min/1.73 m² 5
The initial reversible decrease in eGFR with SGLT2i initiation is generally not a reason to discontinue therapy 7