Management of Chronic Kidney Disease with Hypertension and Diabetes

Initial Assessment and Monitoring

The American Diabetes Association recommends screening annually with spot urinary albumin-to-creatinine ratio and estimated GFR in all patients with type 2 diabetes regardless of duration, and in type 1 diabetes patients with disease duration ≥5 years 2
The American Diabetes Association suggests monitoring frequency should be 1-4 times per year based on CKD stage 2
The American College of Cardiology recommends checking HbA1c every 3 months when therapy changes or targets are not met, and at least twice yearly in stable patients 1

The American College of Cardiology recommends starting 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 1
The American Heart Association suggests initiating ACE inhibitors or ARBs in all patients with diabetes, hypertension, AND albuminuria, titrating to the highest tolerated dose 3, 4, 1
The American College of Cardiology recommends monitoring serum creatinine and potassium within 2-4 weeks after starting or increasing dose of ACE inhibitors or ARBs 4, 1

The American Heart Association recommends targeting <130/80 mmHg for all patients with diabetes and CKD to reduce cardiovascular mortality and slow CKD progression 6, 5
The American College of Cardiology suggests considering lower targets (e.g., <130/80 mmHg) in patients with severely elevated albuminuria (≥300 mg/g creatinine) 6, 5

The American Diabetes Association recommends targeting HbA1c between 6.5-8.0%, individualized based on hypoglycemia risk, life expectancy, comorbidities, and patient preferences 1
The American College of Cardiology suggests intensive glucose control (HbA1c ~7%) delays onset and progression of albuminuria and reduces eGFR decline 6

The American College of Cardiology recommends initiating statin therapy in all patients with type 1 or type 2 diabetes and CKD, regardless of baseline lipid levels, to reduce cardiovascular events and mortality 8, 1
The American Heart Association suggests ensuring level of care for ischemic heart disease is not prejudiced by CKD, as patients with CKD are more likely to have cardiovascular events than progress to end-stage renal disease 7

The American Heart Association recommends limiting protein intake to 0.8 g/kg/day for patients with diabetes and CKD not on dialysis 1
The American College of Cardiology suggests restricting sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day) 7, 1
The American Diabetes Association recommends advising moderate-intensity physical activity for at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 1

The American College of Cardiology recommends reassessing every 3-6 months all cardiovascular and metabolic risk factors, monitoring kidney function, electrolytes, and adjusting medications as CKD progresses 8
The American Heart Association suggests monitoring for acute kidney injury, as all people with CKD are at increased risk 7

The American College of Physicians recommends considering earlier referral for complex cases requiring multidisciplinary management involving nephrologists, endocrinologists, cardiologists, and dietitians 3, 4

The American College of Cardiology recommends never combining ACE inhibitors with ARBs, despite theoretical benefits, as this increases harm 4
The American Heart Association suggests not overlooking cardiovascular disease management, as cardiovascular events are more likely than progression to end-stage renal disease 7