The Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (KDIGO) for Kidney Disease: Improving Global Outcomes (KDIGO) is the first KDIGO guideline on the issue of CKD in the diabetes community. The updated guidance outlines evidence-based clinical practices for treating diabetic and CKD patients, including how to incorporate new treatments into current treatment techniques.

For primary care physicians, the whole guideline is essential reading, but here are KDIGO's ten key update points.

Integrated approach

Diabetes and CKD patients have multisystem disorder that necessitates therapy that includes a base of behavioural intervention (healthy eating, exercise, and no smoking) as well as pharmacologic risk factor control (glucose, lipids, blood pressure).

Dietary approach

Patients should eat a well-balanced, nutritious diet rich in greens, citrus, whole grains, fibre, legumes, plant-based proteins, unsaturated fats, and nuts and low in processed foods, refined sugars, and sugary drinks. Consumption of sodium (<2 g per day) and protein (0.8 g/kg per day) in line with general population guidelines.

Blood glucose tracking

In patients with diabetes and chronic kidney disease, it is recommended to track glycaemic regulation using the A1c test. For patients with advanced chronic kidney disease (especially those on dialysis), the reliability of A1c decreases is questionable, and findings should be viewed cautiously. Additionally, CGM or SMBG can be beneficial, particularly for treatments involved with a risk of hypoglycaemia.

Glycemic objectives

Glycemic reduction targets should be tailored to the person, ranging from 6.5 to 8.0 per cent, taking into account risk factors for hypoglycaemia, such as advanced CKD and forms of glucose-lowering therapy.

Inhibitors of the sodium-glucose cotransporter-2

SGLT2i can be started in patients with type 2 diabetes and chronic kidney disease when their eGFR is >30 ml/min/1.73 m², and should be maintained at lower eGFR levels. Even when blood glucose is still under balance, SGLT2i significantly reduces the risk of CKD development, cardiac failure, and atherosclerotic CV diseases.

Metformin

Patients with T2D and CKD who have an eGFR of well over 30 ml/min/1.73 m2 should take metformin. Metformin is a safe, reliable, and reasonably priced medication that can be used to stabilize blood glucose and prevent diabetic complications in such patients.

Agonists for the glucagon-like peptide-1 receptor

A long-acting GLP-1 RA is prescribed as part of the therapy for patients with T2D and CKD who have not reached individualized glycemic targets despite the use of metformin and SGLT2i, or who are unable to use such drugs.

Blockade of the renin-angiotensin system

Patients with type 1 or type 2 diabetes, hypertension, and chronic albuminuria (ACR >30 mg/g), should be managed with a RAS inhibitor (ACEi or ARB) titrated to the maximum accepted or tolerated level. Potassium and creatinine levels in the blood should be assessed.

Management strategies

A team-based and collaborative approach to managing patients with T2D and CKD should emphasize routine monitoring, regulation of various risk factors, and formal education in self-management in order to preserve kidney function and minimise the likelihood of complications.

Recommendations based on research

There is a dearth of evidence on how to treat diabetes optimally in kidney disease, including dialysis and transplantation, which should be the subject of future research.