Managing & Preventing progression of diabetic kidney disease

Source: https://kdigo.org/guidelines/diabetes-ckd/

1. Changes to lifestyle

Healthy diet, exercise, weight management & no smoking

2. Nutrition

Healthy diet that is high in vegetables, fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, and nuts

Lower in processed meats, refined carbohydrates, and sweetened beverages.

Sodium (<2 g/day) and protein intake (0.8 g/kg/day) as per recommendations for the general population.

3. Medication: SGLT2 inhibitor

A SGLT2i such as dapagliflozin, canagliflozin or empagliflozin should be started for patients with type 2 diabetes (T2D) and chronic kidney disease (CKD) when eGFR is ≥20 ml/min/1.73 m2 (but can be continued after initiation if eGFR drops below this level).

SGLT2i markedly reduce risks of CKD progression, heart failure, and atherosclerotic cardiovascular diseases, even when blood glucose is already controlled.

4. Medication: Metformin

Metformin should be used for patients with T2D and CKD when eGFR is ≥30 ml/min/1.73 m2

5. Control of blood glucose

HbA1c should be measured regularly. Consider continuous glucose monitoring.

Targets for glycemic control should be individualized, ranging from 6.5% to 8.0%.

6. Medication: RAS inhibitors

People with type 1 or type 2 diabetes, hypertension, and albuminuria (persistent ACR ≥30 mg/g) should be treated with an ACEi or ARB, titrated to the maximum approved or highest tolerated dose.

Serum potassium and creatinine should be monitored.

7. Medication: Non-steroidal mineralocorticoid antagonists (ns-MRA)

ns-MRA reduce risks of CKD progression and cardiovascular events for people with T2D and residual albuminuria. They are suggested for patients with T2D, urine ACR ≥30 mg/g, and normal serum potassium on other standard of care therapies.