Management of CKD 3b in Type 1 Diabetes

Introduction to CKD 3b Management

• The American Diabetes Association recommends adding an SGLT2 inhibitor to the current regimen as the single most important intervention to prevent dialysis in patients with type 1 diabetes and CKD 3b 1, 2, 3, 4, 5

Critical Missing Medication: SGLT2 Inhibitor

• SGLT2 inhibitors reduce the risk of kidney failure, dialysis, or renal death by 30-40% in patients with diabetic kidney disease, even when added to maximum ACE inhibitor/ARB therapy 1, 4, 5
• The benefits of SGLT2 inhibitors persist down to eGFR levels of 30 mL/min/1.73 m², independent of glucose-lowering effects 5
• The CREDENCE trial showed that canagliflozin reduced the primary endpoint of chronic dialysis, kidney transplantation, sustained eGFR <15, doubling of serum creatinine, ESRD, or death from ESRD by 30% on top of background ACE inhibitor/ARB therapy in >99% of patients 5
• SGLT2 inhibitors also provide dual kidney and heart protection by reducing cardiovascular death or heart failure hospitalization by 31% 5

Optimize Your Current Blood Pressure Management

• The American Heart Association recommends targeting blood pressure <130/80 mmHg, potentially even lower given CKD 3b with diabetes 1, 2, 3, 4, 6
• ACE inhibitors are the preferred first-line agent for type 1 diabetes with CKD, proven to reduce progression to ESRD 1, 4, 6

Consider Adding Finerenone (Non-Steroidal MRA)

• Finerenone should be considered as the next addition after SGLT2 inhibitor if albuminuria persists, as it reduced the composite kidney outcome by 18% when added to ACE inhibitor/ARB therapy in the FIDELIO-DKD trial 2, 3
• Finerenone also reduced end-stage kidney disease by 36% in patients with moderately elevated albuminuria in the FIGARO-DKD trial 2, 3

Optimize Glycemic Control

• The American Diabetes Association recommends maintaining HbA1c as close to 7% as safely possible without causing hypoglycemia 7, 6
• Tight glycemic control reduces the risk and slows progression of diabetic kidney disease 7, 6

Monitor Albuminuria as a Treatment Target

• The National Kidney Foundation recommends requesting annual urine albumin-to-creatinine ratio (UACR) testing to guide therapy intensity 9, 7
• Reduction in urinary albumin excretion directly correlates with kidney protection and reduced cardiovascular risk 9

Mandatory Nephrologist Referral

• The American Society of Nephrology recommends referral to a nephrologist when eGFR <30 mL/min/1.73 m², but earlier referral is appropriate for patients with CKD 3b and type 1 diabetes 2, 3, 5

Continue Current Lipid Management

• The American College of Cardiology recommends continuing the current atorvastatin and ezetimibe combination for lipid management, as cardiovascular disease is a major cause of mortality in diabetic kidney disease 7

Critical Pitfalls to Avoid

• The European Society of Cardiology recommends never combining ACE inhibitors with ARBs, as this combination increases adverse events without additional kidney or cardiovascular benefits 1, 2, 3, 4, 5