Management of Obese Diabetic Hypertensive Patient with Advanced CKD

Dietary Recommendations

The American College of Physicians and Kidney International recommend an 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 for patients with CKD 1, 2
The National Kidney Foundation recommends maintaining protein intake at 0.8 g protein/kg body weight/day for CKD patients not on dialysis 3, 2
The American Heart Association recommends restricting sodium intake to <2 g of sodium per day (or <5 g of sodium chloride per day) to help control blood pressure and reduce fluid retention in patients with CKD 1, 3
The Kidney International guideline suggests adjusting potassium intake to maintain serum potassium within normal range, particularly important with advanced CKD 4
The Academy of Nutrition and Dietetics recommends engaging registered dietitians and diabetes educators in the multidisciplinary nutrition care for patients with CKD 2

The American College of Sports Medicine recommends advising moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance for patients with CKD 1, 3
The World Health Organization recommends avoiding sedentary behavior in patients with CKD 2
The American Geriatrics Society recommends providing specific advice on intensity (low to moderate) and type of exercise (combination of aerobic and resistance) for patients at higher risk of falls with CKD 2

The American Diabetes Association recommends targeting blood pressure should be <140/90 mmHg for patients with diabetic CKD 5, 6
The National Kidney Foundation recommends using ACE inhibitors or ARBs as first-line therapy for hypertension in diabetic CKD patients 7
The American Diabetes Association recommends avoiding combined use of ACE inhibitors and ARBs due to increased risk of hyperkalemia and acute kidney injury in patients with CKD 5

The American Diabetes Association recommends that metformin is contraindicated (eGFR likely <30 ml/min/1.73m²) in patients with advanced CKD 1, 8
The European Association for the Study of Diabetes recommends that SGLT2 inhibitors are not recommended with eGFR <30 ml/min/1.73m² in patients with CKD 1, 8
The American Diabetes Association recommends insulin therapy for glycemic control in advanced CKD 3
The International Diabetes Federation recommends targeting HbA1c should be individualized, likely around 7-8% given the advanced kidney disease, to avoid hypoglycemia in patients with CKD 1

The American Diabetes Association recommends immediate nephrology referral is necessary with creatinine of 6 (eGFR likely <15 ml/min/1.73m²) for evaluation and planning for renal replacement therapy in patients with CKD 5
The National Kidney Foundation recommends maintaining bicarbonate levels between 24-26 mmol/L in patients with advanced CKD 4
The Academy of Nutrition and Dietetics recommends performing nutritional assessments at least every six months in patients with CKD 4

The American Diabetes Association recommends that patients with a creatinine of 6 likely have stage 5 CKD and will need preparation for dialysis or transplant evaluation 5
The National Kidney Foundation recommends increasing protein intake to 1.0-1.2 g/kg/day if dialysis is initiated, particularly for peritoneal dialysis in patients with CKD 3, 2
The European Renal Association recommends considering the use of potassium binders if hyperkalemia is present in patients with CKD 9
The National Kidney Foundation recommends avoiding substitutes of salt with high potassium content given the advanced CKD 4
The American Geriatrics Society recommends avoiding overly strict dietary restrictions to prevent malnutrition in frail patients who depend on processed foods with CKD 4