Top Takeaways for Clinicians from the

10
KDIGO 2020 Clinical Practice Guideline
for Diabetes Management in CKD

1
Comprehensive care
Patients with diabetes and CKD have multisystem disease that requires Some
patients

treatment including a foundation of lifestyle intervention (healthy diet, Antiplatelet

therapies
exercise, no smoking) and pharmacologic risk factor management Most
patients
(glucose, lipids, blood pressure).
SGLT2 RAS
Nutrition intake

2
inhibitors blockade
All
Patients should consume a balanced, healthy diet that is high in vegetables, patients
fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, Blood
and nuts; and lower in processed meats, refined carbohydrates, and sweet- Glycemic pressure Lipid
control control management
ened beverages. Sodium (<2 g/day) and protein intake (0.8 g/kg/day) in
accordance with recommendations for the general population.

Glycemic monitoring Exercise Nutrition Smoking cessation

3
Diabetes with CKD
It is advised to monitor glycemic control with HbA1c in patients with
diabetes and CKD. For patients with advanced CKD (particularly those on
dialysis), reliability of HbA1c decreases and results should be interpreted
with caution. CGM or SMBG may also be useful, especially for treatment Physical activity
Lifestyle therapy Nutrition
associated with risk of hypoglycemia.
Weight loss

4
Metformin SGLT2 inhibitor
Glycemic targets First-line eGFR eGFR eGFR
Dialysis + Dialysis
therapy
Targets for glycemic control should be individualized ranging from < 45 < 30
Reduce dose Discontinue Discontinue
< 30
Do not initiate Discontinue
<6.5% to <8.0%, taking into consideration risk factors for hypoglycemia,
including advanced CKD and type of glucose-lowering therapy.
GLP-1 receptor agonist
(preferred)
Additional drug therapy as DPP-4 inhibitor Insulin
SGLT2i

5
needed for glycemic control
Sulfonylurea TZD
SGLT2i should be initiated for patients with T2D and CKD when eGFR is ≥30 Alpha-glucosidase inhibitor
ml/min/1.73 m2 and can be continued after initiation at lower levels of • Guided by patient preferences, comorbidities, eGFR, and cost
• Includes patients with eGFR < 30 ml/min per 1.73 m2
eGFR. SGLT2i markedly reduce risks of CKD progression, heart failure, and or treated with dialysis
atherosclerotic cardiovascular diseases, even when blood glucose is already
controlled.
uitable medications
Less s

6
Metformin TZD

itable medicatio
Metformin should be used for patients with T2D and CKD when eGFR is Mo
re su ns
≥30 ml/min/1.73 m2. For such patients, metformin is a safe, effective, and GLP1RA GLP1RA
inexpensive drug to control blood glucose and reduce diabetes compli- mo
rbidity or other
co ch
cations. SU, AGI
nc
e, Heart a
High risk ra DPP4i,
DPP4i, TZD, AGI
ct
e

failure ASCVD
fer

GLP1RA,
insulin, eri
Pre

eGFR < 15 stic insulin

TZD

7
mL/min/1.73 Potent
GLP-1 RA m2 or treatment
with dialysis
glucose-lowering

In patients with T2D and CKD who have not achieved individualized Low cost
Avoid
hypoglycemia
glycemic targets despite use of metformin and SGLT2i, or who are SU, TZD,
GLP1RA,
DPP4i,
unable to use those medications, a long-acting GLP-1 RA is recommend- GLP1RA, AGI Weight Avoid
TZD, AGI SU,
DPP4i, loss injections
ed as part of the treatment. insulin
insulin

GLP1RA DPP4i, TZD, SU, AGI,

oral GLP1RA

8
RAS blockade
Patients with T1D or T2D, hypertension, and albuminuria (persistent ACR SU, insulin, TZD GLP1RA, insulin

>30 mg/g) should be treated with a RAS inhibitor (ACEi or ARB), titrated
to the maximum approved or highest tolerated dose. Serum potassium
and creatinine should be monitored.

Poorly-informed patients Empowered patients

9
with suboptimal control Register with optimal control
Approaches to management Risk assessment

A team-based and integrated approach to manage these patients should

focus on regular assessment, control of multiple risk factors, and
Goals
structured education in self-management to protect kidney function and
Treat to multiple targets
reduce risk of complications. Relay (glycemia, BP, lipids)
Reinforce Use of organ-protective drugs Risk
Recall (RASi, SGLT2i, GLP1RA, statins) stratification

10
Ongoing support to promote

Research recommendations self-care

There is a paucity of data on optimal management of diabetes in kidney

failure, including dialysis and transplantation, which should be a focus Review
for future studies. Risk factor
control
Uncoordinated care Coordinated care

ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-creatinine ratio; ARB, angiotensin II receptor blocker; CKD, chronic kidney disease; eGFR, estimated
glomerular filtration rate; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HbA1c, hemoglobin A1c (glycated hemoglobin); RAS, renin-angiotensin system;
SGLT2i, sodium-glucose cotransporter-2 inhibitor; SMBG, self-monitoring blood glucose; T1D, type 1 diabetes; T2D, type 2 diabetes