Management of CKD Stage 5 with Diabetes Mellitus and Hypertension

Pharmacologic Management Strategy

The American College of Cardiology recommends starting an SGLT2 inhibitor immediately if eGFR ≥20 mL/min/1.73 m², regardless of current glycemic control, for patients with CKD stage 5, diabetes, and hypertension 1
The Kidney International guideline suggests continuing ACE inhibitor or ARB therapy if the patient has albuminuria and was previously tolerating these agents, with a strength of evidence level of high 2, 3
The American Diabetes Association recommends adding a GLP-1 receptor agonist if glycemic targets are not met with SGLT2 inhibitors or if SGLT2 inhibitors cannot be used, with a moderate level of evidence 1
The National Kidney Foundation guideline advises targeting HbA1c between <6.5% and <8.0%, individualized based on hypoglycemia risk, life expectancy, comorbidities, and patient preferences, with a high level of evidence 1

The American Heart Association recommends targeting blood pressure <140/90 mmHg for CKD stage 5, with a high level of evidence 4
The European Society of Cardiology guideline suggests using ACE inhibitors or ARBs as preferred agents if albuminuria is present, as they reduce progression to end-stage renal disease, with a high level of evidence 4

The American College of Cardiology recommends initiating statin therapy in all patients with diabetes and CKD, with a high level of evidence 1
The Kidney International guideline suggests using aspirin lifelong for secondary prevention in those with established cardiovascular disease, with a moderate level of evidence 2, 3

The Academy of Nutrition and Dietetics recommends limiting protein intake to 0.8 g/kg/day for patients with diabetes and CKD not on dialysis, with a moderate level of evidence 1
The American Heart Association advises restricting sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day), with a high level of evidence 1

The American Diabetes Association recommends screening regularly for retinopathy, neuropathy, and foot complications, with a high level of evidence 2
The National Kidney Foundation guideline suggests performing comprehensive foot examination including visual inspection, Semmes-Weinstein monofilament testing, 128-Hz tuning fork for vibratory sensation, and pedal pulse evaluation annually, with a moderate level of evidence 5

The Kidney International guideline advises structured, monitored, individualized patient education regarding dialysis options and transplantation, with a high level of evidence 2
The National Kidney Foundation recommends preparing for dialysis or transplantation as CKD stage 5 approaches end-stage kidney disease, with a high level of evidence 2