The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care.

Recommendations

Chronic Kidney Disease - Screening

At least annually, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated glomerular filtration rate should be assessed in patients with type 1 diabetes with duration of ≥5 years and in all patients with type 2 diabetes regardless of treatment.

Patients with diabetes and urinary albumin ≥300 mg/g creatinine and/or an estimated glomerular filtration rate 30–60 mL/min/1.73 m2 should be monitored twice annually to guide therapy.

Chronic Kidney Disease - Treatment

Optimize glucose control to reduce the risk or slow the progression of chronic kidney disease.

Nutrition

·       For people with nondialysis-dependent stage 3 or higher chronic kidney disease, dietary protein intake should be a maximum of 0.8 g/kg body weight per day (the recommended daily allowance). A For patients on dialysis, higher levels of dietary protein intake should be considered, since malnutrition is a major problem in some dialysis patients.

·       Restriction of dietary sodium (to <2,300 mg/day) may be useful to control blood pressure and reduce cardiovascular risk, and restriction of dietary potassium may be necessary to control serum potassium concentration. These interventions may be most important for patients with reduced eGFR, for whom urinary excretion of sodium and potassium may be impaired.

Selection of Glucose-Lowering Medications

·       For patients with type 2 diabetes and diabetic kidney disease, use of a sodium–glucose co-transporter 2 (SGLT2) inhibitors such as canagliflozin, dapagliflozin, and empagliflozin in patients with an estimated glomerular filtration rate ≥25 mL/min/1.73 m2 and urinary albumin ≥300 mg/g creatinine is recommended to reduce chronic kidney disease progression and cardiovascular events.

·       In patients with type 2 diabetes and chronic kidney disease, consider use of sodium–glucose cotransporter 2 inhibitors additionally for cardiovascular risk reduction when estimated glomerular filtration rate and urinary albumin creatinine are ≥25 mL/min/1.73 m2 or ≥300 mg/g, respectively.

·       In patients with chronic kidney disease who are at increased risk for cardiovascular events or chronic kidney disease progression or are unable to use a sodium–glucose co-transporter 2 inhibitor, a nonsteroidal mineralocorticoid receptor antagonist (finerenone) is recommended to reduce chronic kidney disease progression and cardiovascular events.

·       In patients with chronic kidney disease who have ≥300 mg/g urinary albumin, a reduction of 30% or greater in mg/g urinary albumin is recommended to slow chronic kidney disease progression.

Cardiovascular Disease and Blood Pressure

·       Optimization of blood pressure control and reduction in blood pressure variability to reduce the risk or slow the progression of chronic kidney disease is recommended.

·       Do not discontinue renin-angiotensin system blockade for minor increases in serum creatinine (≤30%) in the absence of volume depletion.

·       In nonpregnant patients with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker is recommended for those with modestly elevated urinary albumin-to-creatinine ratio (30–299 mg/g creatinine) B and is strongly recommended for those with urinary albumin-to-creatinine ratio ≥300 mg/g creatinine and/or estimated glomerular filtration rate <60 mL/min/1.73 m2.

·       Periodically monitor serum creatinine and potassium levels for the development of increased creatinine or changes in potassium when ACE inhibitors, angiotensin receptor blockers, or diuretics are used.

·       An ACE inhibitor or an angiotensin receptor blocker is not recommended for the primary prevention of chronic kidney disease in patients with diabetes who have normal blood pressure, normal urinary albumin-to-creatinine ratio (<30 mg/g creatinine), and normal estimated glomerular filtration rate.

Referral to a Nephrologist

·       Patients should be referred for evaluation by a nephrologist if they have an estimated glomerular filtration rate <30 mL/min/1.73 m2.

·       Promptly refer to a nephrologist for uncertainty about the etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease.