A health care provider can diagnose high blood pressure by measuring blood pressure on a regular basis. See "Patient education: High blood pressure in adults Beyond the Basics ". The treatment of high blood pressure varies. If you have mild hypertension, your health care provider may recommend weight loss, exercise, decreasing the amount of salt in the diet, quitting smoking, and decreasing alcohol intake.

These measures can sometimes reduce blood pressure to normal. See "Patient education: High blood pressure, diet, and weight Beyond the Basics ". If these measures are not effective or your blood pressure needs to be lowered quickly, your provider will likely recommend one of several high blood pressure medications.

Your provider can discuss the pros and cons of each medication and the goals of treatment. See "Patient education: High blood pressure treatment in adults Beyond the Basics ". Blood pressure medications — All people with diabetic kidney disease need at least one medication to lower their blood pressure, and in most cases two medications are needed.

Several medications can be used for this purpose, but a medication known as an angiotensin-converting enzyme inhibitor abbreviated ACE inhibitor or a related drug known as an angiotensin receptor blocker ARB should be used because they limit the worsening of kidney disease.

ACE inhibitors and ARBs are particularly useful for people with diabetic kidney disease because they decrease the amount of albumin in the urine and can prevent or slow the progression of diabetes-related kidney disease. In fact, the kidney benefits of ACE inhibitors and ARBs are so robust that health care providers sometimes prescribe them for people with diabetic kidney disease who have normal blood pressure.

Still, despite their kidney-protecting abilities, ACE inhibitors and ARBs do have their downsides. For instance, ACE inhibitors cause a persistent dry cough in 5 to 20 percent of the people who take them, even up to 50 percent among Asian populations.

Some people get used to the cough; others find it so disruptive that they cannot continue taking an ACE inhibitor. For them, ARBs are often a good alternative, because ARBs do not cause a cough.

In rare cases, you can have more serious side effects with ACE inhibitors and ARBs. These include a condition called hyperkalemia, in which too much potassium accumulates in the blood. To monitor for these and other side effects, health care providers sometimes run blood tests soon after starting these drugs.

In some people, the medications will need to be stopped. SGLT2 inhibitors — In addition to the measures described above, some people with type 2 diabetes and kidney disease will get a medication called a sodium-glucose co-transporter 2 SGLT2 inhibitor.

These medications lower blood sugar by increasing the excretion of sugar in the urine; they include canagliflozin brand name: Invokana , empagliflozin brand name: Jardiance , and dapagliflozin brand name: Farxiga.

Your health care provider can talk to you about whether you are a candidate for treatment with an SGLT2 inhibitor if you do not already take one ; this will depend on how advanced your kidney disease is and how much albumin is in your urine. Ongoing monitoring — After beginning treatment and lifestyle changes to stall kidney disease, you will need to have repeat urine and blood tests to determine if urine albumin levels have improved.

If the urine albumin levels have not improved or your kidney function has worsened, your health care provider may need to adjust your medications or recommend other strategies to protect your kidneys. PREGNANCY AND DIABETIC KIDNEY DISEASE. If you have diabetes and are interested in getting pregnant, it is important to talk with your health care provider well in advance, especially if you have diabetic kidney disease.

Diabetes and its attendant problems can increase the risk of complications in pregnancy, especially in women with decreased kidney function. However, many women with mild diabetic kidney disease have normal pregnancies and healthy babies.

To ensure the best outcome with a pregnancy, the most important thing you can do is to keep your blood sugar and blood pressure under tight control.

However, women who are pregnant or attempting to get pregnant should not take angiotensin-converting enzyme ACE inhibitors or angiotensin receptor blockers ARBs , as these drugs can cause birth defects. Instead, other medications such as calcium channel blockers are used during pregnancy to keep the blood pressure in check.

See "Patient education: Care during pregnancy for patients with type 1 or 2 diabetes Beyond the Basics ". If the steps you need to take to protect your kidneys sound overwhelming, keep this in mind; controlling your blood sugar and blood pressure can help to reduce the risk or severity of several other debilitating diabetes complications, including:.

The same measures that are used in the treatment of diabetic kidney disease are also useful in preventing it. That's true for the lifestyle choices mentioned above, as well as for the tight control of blood sugar levels and blood pressure. Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site www. Related topics for patients, as well as selected articles written for health care professionals, are also available.

Some of the most relevant are listed below. Patient level information — UpToDate offers two types of patient education materials. The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition.

These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Type 2 diabetes The Basics. Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.

These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Chronic kidney disease Beyond the Basics Patient education: Dialysis or kidney transplantation — which is right for me? Beyond the Basics Patient education: Diabetic neuropathy Beyond the Basics Patient education: Protein in the urine proteinuria Beyond the Basics Patient education: Low-sodium diet Beyond the Basics Patient education: Quitting smoking Beyond the Basics Patient education: Diet and health Beyond the Basics Patient education: Exercise Beyond the Basics Patient education: Losing weight Beyond the Basics Patient education: Glucose monitoring in diabetes Beyond the Basics Patient education: High blood pressure in adults Beyond the Basics Patient education: High blood pressure, diet, and weight Beyond the Basics Patient education: High blood pressure treatment in adults Beyond the Basics Patient education: Care during pregnancy for patients with type 1 or 2 diabetes Beyond the Basics.

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based.

Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults Moderately increased albuminuria microalbuminuria in type 1 diabetes mellitus Moderately increased albuminuria microalbuminuria in type 2 diabetes mellitus Diabetic kidney disease: Pathogenesis and epidemiology Kidney transplantation in diabetic kidney disease Treatment of diabetic kidney disease Major side effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers Pregnancy and contraception in patients with nondialysis chronic kidney disease.

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View Topic. Font Size Small Normal Large. Patient education: Diabetic kidney disease Beyond the Basics. Formulary drug information for this topic. No drug references linked in this topic.

Find in topic Formulary Print Share. Author: George L Bakris, MD Section Editors: Richard J Glassock, MD, MACP David M Nathan, MD Deputy Editor: John P Forman, MD, MSc Contributor Disclosures. All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan This topic last updated: Mar 15, DIABETIC KIDNEY DISEASE OVERVIEW People with diabetes have a lot to juggle when it comes to their health care.

DIABETIC KIDNEY DISEASE SYMPTOMS Diabetic kidney disease commonly causes no symptoms until at least 80 percent of your kidneys' function is lost. DIABETIC KIDNEY DISEASE RISK FACTORS Having a family history of kidney disease or belonging to certain ethnic groups eg, African American, Mexican, Pima Indian can increase your risk of diabetic kidney disease.

DIABETIC KIDNEY DISEASE TREATMENT People with diabetes often focus on keeping their blood sugar levels in the right ranges. PREGNANCY AND DIABETIC KIDNEY DISEASE If you have diabetes and are interested in getting pregnant, it is important to talk with your health care provider well in advance, especially if you have diabetic kidney disease.

Patient education: Type 2 diabetes The Basics Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.

Beyond the Basics Patient education: Diabetic neuropathy Beyond the Basics Patient education: Protein in the urine proteinuria Beyond the Basics Patient education: Low-sodium diet Beyond the Basics Patient education: Quitting smoking Beyond the Basics Patient education: Diet and health Beyond the Basics Patient education: Exercise Beyond the Basics Patient education: Losing weight Beyond the Basics Patient education: Glucose monitoring in diabetes Beyond the Basics Patient education: High blood pressure in adults Beyond the Basics Patient education: High blood pressure, diet, and weight Beyond the Basics Patient education: High blood pressure treatment in adults Beyond the Basics Patient education: Care during pregnancy for patients with type 1 or 2 diabetes Beyond the Basics Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings.

Diabetic nephropathy: diagnosis, prevention, and treatment. Diabetes Care ; An ACEi or ARB is recommended for patients with T1D or T2D who have hypertension and albuminuria, titrated to the maximum antihypertensive or highest tolerated dose.

Statin therapy is a cornerstone of therapy for the primary and secondary prevention of ASCVD among people with diabetes and CKD. The KDIGO Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease recommended statin initiation for most adults with diabetes and CKD who are not treated with dialysis 46 , These recommendations are based largely on results of the Study of Heart and Renal Protection SHARP trial of CKD Additional evidence from subsequent trials was incorporated into recommendations in the ADA Standards of Care, which are endorsed by this consensus statement.

An exception may be patients with kidney failure treated with dialysis for whom primary prevention of ASCVD events with a statin has been generally ineffective 47 , 49 , High-intensity statin is recommended for secondary prevention for all patients with known ASCVD. For some patients, intensification of statin therapy for primary prevention , addition of ezetimibe, or addition of a PCSK-9 inhibitor is recommend based on ASCVD risk and attained LDL cholesterol concentrations.

For patients with high triglyceride or low HDL levels, intensification of lifestyle intervention, optimization of glycemic control, and then consideration of icosapent ethyl are advised 51 Supplementary Table 1.

A statin is recommended for all patients with T1D or T2D and CKD, moderate intensity for primary prevention of ASCVD or high intensity for patients with known ASCVD and some patients with multiple ASCVD risk factors.

The ADA Standards Care and the KDIGO guideline recommend early initiation of metformin plus an SGLT2 inhibitor in most patients with T2D and CKD 2 , 17 Table 1. Additional glucose-lowering agents can then be added as needed to meet individualized glycemic targets based on patient-specific considerations 2 , 17 Table 2.

Prescription of glucose-lowering medications may be limited by eGFR Table 3. Appropriate dose adjustment based on eGFR is important for medications that increase risk of side effects with low eGFR or undergo elimination through the kidney Table 4.

When needed, careful use and titration of insulin and sulfonylurea agents is recommended to avoid hypoglycemia. Key glucose-lowering agent recommendations for patients with T2D and CKD from ADA and KDIGO 2 , The ADA issues an A level of evidence for clear or supportive evidence from well-conducted, generalizable randomized control trials that are adequately powered and a B level of evidence for supportive evidence from well-conducted cohort or case-control studies.

KDIGO uses the GRADE framework, with 1A indicating a strong recommendation based on high-quality evidence and 1B indicating a strong recommendation based on moderate-quality evidence. ADA recommendations Considerations for selecting glucose-lowering agents in patients with T2D and CKD 2 , ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; DPP-4, dipeptidyl peptidase 4; GLP-1, glucagon-like peptide 1; SGLT2, sodium—glucose cotransporter 2.

eGFR, estimated glomerular filtration rate; GLP-1, glucagon-like peptide 1; SGLT2i, sodium—glucose cotransporter 2 inhibitor. Glucose-lowering efficacy is reduced with SGLT2i as eGFR declines, but kidney and cardiovascular benefits are preserved.

Higher dose can be used but is not effective for glucose lowering and does not offer further clinical benefit in this range of eGFR. Dulaglutide, liraglutide, and injectable semaglutide have demonstrated evidence of cardiovascular benefit in large cardiovascular outcome trials.

CV, cardiovascular; DPP-4, dipeptidyl peptidase 4; GFR, estimated glomerular filtration rate; GLP-1, glucagon-like peptide 1; SGLT2, sodium—glucose cotransporter 2.

Metformin has been proven to be a safe, effective, and affordable foundation for glycemic control in T2D. Metformin is excreted unchanged in urine, with the label including a boxed warning for increased risk of lactic acidosis in patients with CKD due to impaired metformin excretion Evidence, however, suggests the overall risk for metformin-associated lactic acidosis is low 53 , and the U.

Food and Drug Administration has revised the U. Most episodes of metformin-associated lactic acidosis occur concurrent with other acute illness, often when acute kidney injury AKI contributes to reduced metformin clearance.

Therefore, sick day protocols that specify holding metformin doses during acute illness may help reduce the risk of metformin-associated lactic acidosis. This recommendation is based on strong evidence that SGLT2i reduce CKD progression, HF, and ASCVD risk in patients with T2D and CKD.

These benefits are independent of glycemia, and an SGLT2i should be used for patients with T2D and CKD even if glycemic targets are already attained.

While an SGLT2i will usually be added to lifestyle and metformin therapy, SGLT2i treatment without metformin may be reasonable for patients with eGFR too low for safe prescription of metformin, who do not tolerate metformin, or who do not need metformin to achieve glycemic targets.

To date, two clinical trials with primary kidney disease outcomes using canagliflozin and dapagliflozin Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation [CREDENCE] and Dapagliflozin And Prevention of Adverse outcomes in Chronic Kidney Disease [DAPA-CKD] demonstrated significant benefit for composite outcomes including end points of substantial eGFR decline, kidney failure, and mortality 54 , Evidence from combined major SGLT2i trials, however, suggests that kidney and cardiovascular benefits are consistent irrespective of baseline albuminuria 56 , including in patients with normal albumin excretion, as reflected in the KDIGO recommendation and consensus statement supporting SGLT2i use in most patients with T2D and CKD 2.

The lower limit of eGFR for which initiation of SGLT2i is recommended has changed over time as new data have rapidly become available. Moreover, SGLT2i have been observed to have consistent efficacy and safety across studied ranges of eGFR Further data are anticipated from the EMPA-KIDNEY trial EMPA-KIDNEY: The Study of Heart and Kidney Protection with Empagliflozin [clinical trial reg.

NCT, ClinicalTrials. Like CREDENCE and DAPA-CKD, EMPA-KIDNEY was stopped early for clear positive efficacy 63 ; corresponding expansion of the indications for use of an SGLT2i in CKD may be further supported based on these findings.

SGLT2i initiation is associated with a reversible decline in eGFR, but this generally does not require drug discontinuation. In fact, SGLT2i use appears to protect patients from AKI Notably, protocols for both CREDENCE and DAPA-CKD specified continuation of study drug when eGFR fell below initiation thresholds.

Therefore, it is reasonable to continue therapy if the eGFR falls below the initiation thresholds unless the patient is not tolerating treatment or KRT is initiated 2. Hypovolemia and hypoglycemia may occur with SGLT2i, but absolute risks are low, especially at low eGFR.

Therefore, adjustment of background therapies is generally not required when initiating an SGLT2i, but it may be prudent in some patients, and follow-up to reassess volume status and glycemia is important Euglycemic ketoacidosis with minimal to no elevation in blood glucose may occur in patients taking SGLT2i.

Patients with T2D requiring insulin are at particular risk. To mitigate risk, it is important to maintain at least low-dose insulin and consider pausing SGLT2i treatment during periods of acute illness or stressors.

Blood or urine ketone monitoring may be used for ketosis detection. Patients with signs, symptoms, or biochemical evidence of ketoacidosis should discontinue SGLT2i therapy and seek immediate medical attention.

Genital mycotic infections are a known complication of SGLT2i. The risk is higher for women than men. Daily hygienic measures may lessen this risk, and most genital mycotic infections are easily treated, but severe cases of Fournier gangrene have been reported.

Additional research is needed to determine the role of SGLT2i in improving kidney outcomes in patients with T1D, among whom diabetic ketoacidosis is more common, and posttransplant, in which case immunosuppression may modify infection risks For patients with T2D and CKD requiring additional glucose-lowering agents, selection should be made in consideration of patient- and medication-specific considerations Table 2.

Similarly, the ADA gives strong support to use of GLP-1 receptor agonists in patients with T2D and CKD or ASCVD in consideration of their primary cardiovascular and secondary kidney benefits in large cardiovascular outcomes trials Notably, GLP-1 receptor agonists retain glycemic efficacy and safety even in advanced CKD stages.

In cardiovascular outcomes trials, GLP-1 receptor agonists reduced risk of major adverse cardiovascular events MACE in patients with T2D 67 — Although most participants in the cardiovascular outcomes trials of GLP-1 receptor agonists had established cardiovascular disease, the MACE reduction was similar between those with and without previous cardiovascular or kidney disease The GLP-1 receptor agonists with favorable CKD outcomes include lixisenatide, exenatide once weekly , liraglutide, semaglutide, albiglutide, dulaglutide, and efpeglenatide 67 , 68 , 70 , 72 — In a meta-analysis of eight cardiovascular outcomes trials, GLP-1 receptor agonists significantly reduced risk for a composite kidney disease outcome macroalbuminuria, eGFR decline, progression to kidney failure, or death from kidney disease compared with placebo, largely driven by reduction in albuminuria In a glycemic efficacy and safety trial in patients with moderate-to-severe CKD CKD stages G3 and G4 , dulaglutide was compared with insulin glargine as basal therapy 71 , Dulaglutide produced similar glycemic control but resulted in significantly slower GFR decline.

Nausea, vomiting, and diarrhea are the most common side effects of GLP-1 receptor agonists. GLP-1 receptor agonist treatment is not recommended in patients at risk for thyroid C-cell tumors e.

GLP-1 receptor agonists that have shown cardiovascular and CKD benefits liraglutide, semaglutide, albiglutide [not currently available], and dulaglutide are preferred agents. GLP-1 receptor agonists do not cause hypoglycemia per se but, when used with insulin or insulin secretagogues, doses of these drugs may be reduced to avoid hypoglycemia.

However, in moderate-to-severe CKD CKD stages G3 and G4 , rates of hypoglycemia are reduced by one-half even with concurrent insulin therapy For T1D, insulin remains the only approved therapy. Doses are titrated to achieve individualized glycemic goals but may need to be decreased in comparison with earlier stages of CKD due to reduced insulin clearance and other changes in metabolism with advanced CKD In T2D, advanced CKD is a risk factor for hypoglycemia 29 , 79 and, when possible, drugs that control glycemia without increasing risk of hypoglycemia are preferred.

However, SGLT2i have minimal effects on glycemia in this range of eGFR and are of use mainly for kidney and cardiovascular benefits not mediated through glycemia. GLP-1 receptor agonists reduced ASCVD events and albuminuria in large RCTs and, thus, are theoretically appealing for people with T2D and CKD but have not been prospectively tested for cardiovascular efficacy or safety in this population.

GLP-1 receptor agonists induce weight loss and can cause nausea and vomiting, so caution is warranted among patients with or at risk for malnutrition.

Notably, in people with T2D and advanced CKD who have obesity exceeding BMI limits required for kidney transplant listing, GLP-1 receptor agonists can be used to aid with weight loss that may facilitate qualification for transplant.

Thiazolidinediones improve insulin sensitivity, a common abnormality in advanced CKD, and retain antihyperglycemic effects in this population.

Fluid retention and HF are concerns with low eGFR and require careful monitoring. Insulin and short-acting sulfonylureas are often necessary to control glucose when medications with less propensity to cause hypoglycemia are contraindicated, not tolerated, unavailable, or insufficient.

Patients with a kidney transplant have been excluded from most clinical trials of glucose-lowering therapy. Therefore, data must be extrapolated from general populations with diabetes, with consideration of differences in diabetes pathophysiology i. High-quality trial data are needed for this population.

For T2D and posttransplant diabetes, it is reasonable to treat kidney transplant recipients with metformin according to eGFR, as for the broader population with T2D, because risks of metformin are related to kidney function 80 — SGLT2i are promising drugs for kidney transplant recipients because they reduce intraglomerular pressure, which may be elevated in single functional kidneys, and may improve graft outcomes through this and other mechanisms.

However, these benefits have not been confirmed in clinical trials, and there is a theoretical concern that infection risks i. Therefore, more data are needed prior to making recommendations for or against treatment with SGLT2i for kidney transplant recipients.

Kidney transplantation and its treatments do not substantially modify the known risks and benefits of other glucose-lowering medications, other than restrictions associated with eGFR. RAS inhibition with ACEi or ARBs has been standard of care in patients with T1D and T2D and CKD for decades.

Rarely, patients with albuminuria have normal BP, and in this situation, evidence for treatment with RAS inhibition is less strong. Although short-term studies demonstrated added benefit of the combination of ACEi and ARBs in albuminuria reduction, long-term studies showed no benefit and more adverse events, particularly hyperkalemia and AKI, and thus avoidance of this combination is recommended.

The steroidal mineralocorticoid receptor antagonist spironolactone is effective for management of resistant hypertension and treatment of primary hyperaldosteronism, in the setting of normal eGFR. Additionally, spironolactone reduces mortality in patients with HF with reduced ejection fraction.

However, spironolactone causes hyperkalemia, particularly with reduced kidney function i. There are no long-term kidney outcome studies with spironolactone, and only one study in heart failure with reduced ejection fraction with a mean follow-up of 2 years that showed benefit.

A novel class of ns-MRAs, including esaxerenone and finerenone, has recently been investigated among people with T2D and CKD, added to RAS inhibition.

Esaxerenone lowered BP and albuminuria with limited changes in potassium, but long-term studies with clinical end points are lacking Serum potassium was monitored regularly, and 2. In Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease FIGARO-DKD , the primary composite cardiovascular end point MACE or hospitalization for HF was reduced with finerenone compared with placebo, with estimates of effect for kidney outcomes and hyperkalemia similar to those seen in FIDELIO-DKD Moreover, the risk of hyperkalemia was significantly reduced by the presence of an SGLT2i These effects appear to be additive, based on preclinical studies, to those of SGLT2i and GLP-1 receptor agonists, though further clinical research on these combinations is needed.

Therefore, it is reasonable to add finerenone to the treatment regimen of patients with T2D who have any level of persistent albuminuria despite current standard of care treatment with glucose-lowering and antihypertensive medications Fig.

Food and Drug Administration label. Potassium should be followed 4 weeks after dose change and regularly during treatment.

The ADA Standards of Care and KDIGO guideline are aligned on issues of CKD screening and diagnosis, glycemia monitoring, lifestyle therapies, treatment goals, and pharmacologic management 1 , 2. Both recommend comprehensive care in which pharmacotherapy that is proven to improve clinical kidney and cardiovascular outcomes is layered upon a foundation of healthy lifestyle approaches.

This consensus approach to management is based on high-quality evidence. Randomized clinical trial data are most abundant for drug therapies, and other professional societies have also made similar recommendations for use of these agents.

Implementation of proven therapies is paramount to improving health outcomes. There is a critical need for patients with diabetes and CKD to be treated in accord with the most up-to-date recommendations. The ADA and KDIGO, individually and now in combination, offer clear guidance on applying and prioritizing interventions.

High cost, limited workforce, and other resource constraints in health care systems will limit implementation of some recommendations among individuals and populations, and efforts to improve accessibility are essential to maximizing benefit and minimizing disparities.

Investigation remains active in the fields of diabetes, CKD, and cardiovascular disease, and additional data on existing and novel approaches are anticipated.

Clinical practice guidelines will continue to evolve. When possible, consensus approaches to diagnosis and management will help interpret new data in context and translate discoveries to improved outcomes for patients. This article is featured in a podcast available at diabetesjournals.

This article is being simultaneously published in Diabetes Care and Kidney International. Either of these versions may be used in citing this article. A consensus report of a particular topic contains a comprehensive examination and is authored by an expert panel i.

Consensus reports may also highlight gaps in evidence and propose areas of future research to address these gaps. A consensus report is not an American Diabetes Association ADA position but represents expert opinion only and is produced under the auspices of the ADA by invited experts.

A consensus report may be developed after an ADA Clinical Conference or Research Symposium. Duality of Interest. He is a consultant to or advisory board member of AstraZeneca, Bayer, Boehringer Ingelheim, Cyclerion Therapeutics, George Clinical, Goldfinch Bio, and Ironwood Pharmaceuticals.

He is also deputy editor for the Clinical Journal of the American Society of Nephrology. has received research grants from Goldfinch Bio, Bayer, and Travere Therapeutics. She is a consultant to or advisory board member of Eli Lilly, AstraZeneca, Boehringer Ingelheim, Gilead Sciences, Goldfinch Bio, Novo Nordisk, Bayer, and Travere Therapeutics.

has received a research grant from Dexcom and honoraria from AstraZeneca. She has also received funding from Fresenius Medical Care and ReCor Medical. She is the president-elect of the National Kidney Foundation.

is a consultant to or advisory board member of Merck, Bayer, KBP Biosciences, Ionis Pharmaceuticals, Alnylam Pharmaceuticals, AstraZeneca, Quantum Genomics, Horizon Therapeutics, Novo Nordisk, DiaMedica Therapuetics, and inRegen. No other potential conflicts of interest relevant to this article were reported.

Author Contributions. and G. were co-chairs for the consensus report writing group. were the writing group members for the ADA. were the writing group members for the KDIGO. All authors were responsible for drafting the report and revising it critically for important intellectual content.

All authors approved the version to be published. Sign In or Create an Account. Search Dropdown Menu. header search search input Search input auto suggest. filter your search All Content All Journals Diabetes Care. Advanced Search. User Tools Dropdown. Sign In.

Skip Nav Destination Close navigation menu Article navigation. Volume 45, Issue Previous Article Next Article. Screening and Diagnosis. Comprehensive Care. Treatment Targets and Pharmacotherapy. Article Information. Article Navigation. Consensus Reports October 03 Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association ADA and Kidney Disease: Improving Global Outcomes KDIGO Ian H.

de Boer de Boer. Corresponding author: Ian H. de Boer, deboer u. This Site. Google Scholar. Kamlesh Khunti ; Kamlesh Khunti. Tami Sadusky ; Tami Sadusky. Katherine R.

Tuttle ; Katherine R. Joshua J. Neumiller ; Joshua J. Connie M. Rhee ; Connie M. Sylvia E. Rosas ; Sylvia E. Peter Rossing ; Peter Rossing. George Bakris George Bakris. Diabetes Care ;45 12 — Article history Received:. Get Permissions. toolbar search Search Dropdown Menu.

toolbar search search input Search input auto suggest. Figure 1. View large Download slide. Figure 2. Figure 3. Figure 4. Table 1 Key glucose-lowering agent recommendations for patients with T2D and CKD from ADA and KDIGO 2 , Medication class.

ADA Standards of Medical Care in Diabetes. KDIGO Guideline for Diabetes Management in Chronic Kidney Disease. View Large. Table 2 Considerations for selecting glucose-lowering agents in patients with T2D and CKD 2 , View large. a Benefit supported by primary and secondary outcome data.

b Benefit supported by secondary outcome data. c Benefit or risk is agent specific. Table 3 Key monitoring and risk mitigation strategies for preferred glucose-lowering agents.

American Diabetes Association. Search ADS. Kidney Disease: Improving Global Outcomes KDIGO Diabetes Work Group. KDIGO Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. International Diabetes Federation.

Accessed 1 October Clinical manifestations of kidney disease among US adults with diabetes, Global kidney health and beyond: a roadmap for closing gaps in care, research, and policy. United States Renal Data System.

National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis. Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention Chronic Kidney Disease Surveillance Team. Global and regional estimates and projections of diabetes-related health expenditure: results from the International Diabetes Federation Diabetes Atlas, 9th edition.

Health care costs associated with macrovascular, microvascular, and metabolic complications of type 2 diabetes across time: estimates from a population-based cohort of more than 0. The impact of cardiovascular disease and chronic kidney disease on life expectancy and direct medical cost in a year diabetes cohort study.

People who develop diabetic kidney disease usually have no symptoms early on, although the condition puts them at risk of developing more serious kidney disease. The kidneys play an important role in the body: they filter the blood, removing waste products and excess salt and water.

If the kidneys become diseased, they falter in their task, leaving the blood polluted. Finding out that you have early diabetic kidney disease can alert you that your kidneys are in danger. It is important to take steps to protect your kidneys before the problem advances.

Information about advanced kidney disease is also available. See "Patient education: Chronic kidney disease Beyond the Basics ". In some cases, diabetic kidney disease can eventually cause the kidneys to stop working altogether. If that happens to you, you will need to have a kidney transplant or dialysis, a procedure that filters the blood artificially several times a week.

Also, if your kidneys are diseased, your risk of heart attacks and heart failure could be higher. See "Patient education: Dialysis or kidney transplantation — which is right for me?

Beyond the Basics ". DIABETIC KIDNEY DISEASE SYMPTOMS. Diabetic kidney disease commonly causes no symptoms until at least 80 percent of your kidneys' function is lost.

To detect diabetic kidney disease, health care providers rely on tests that measure protein albumin levels in the urine and blood tests to evaluate the level of kidney function.

When the kidneys are working normally, they prevent albumin from leaking into the urine, so finding albumin in the urine is a sign that the kidneys are in trouble. Often people who have diabetic kidney disease also have high blood pressure.

DIABETIC KIDNEY DISEASE RISK FACTORS. Having a family history of kidney disease or belonging to certain ethnic groups eg, African American, Mexican, Pima Indian can increase your risk of diabetic kidney disease. Although you cannot do anything to change your family history, there are several factors that increase your risk of developing diabetic kidney disease that you can change and control.

These include:. DIABETIC KIDNEY DISEASE DIAGNOSIS. Urine tests are recommended once per year in people with type 1 diabetes, beginning about five years after diagnosis, and in people with type 2 diabetes, starting at the time of diagnosis.

The urine test is looking for a protein called albumin. If there is a very large amount of albumin in your urine, it means you have diabetic kidney disease. You may be told that you have "microalbuminuria" or "high albuminuria".

That simply means that you have trace amounts of albumin in your urine, but it still means that you are at risk for getting diabetic kidney disease, assuming you do not have kidney disease caused by another condition. See "Patient education: Protein in the urine proteinuria Beyond the Basics ".

The same urine test that is used to diagnose diabetic kidney disease will also be used to monitor your condition over time. See 'Ongoing monitoring' below. The key complication of diabetic kidney disease is more advanced kidney disease, called chronic kidney disease.

Chronic kidney disease can, in turn, progress even further, eventually leading to total kidney failure and the need for dialysis or kidney transplantation.

DIABETIC KIDNEY DISEASE TREATMENT. People with diabetes often focus on keeping their blood sugar levels in the right ranges. And while it is important to control blood sugar, it turns out that controlling blood pressure is at least as important.

That's because high blood sugar and high blood pressure work in concert to damage the blood vessels and organ systems. For these reasons, the most important things you can do to stall kidney disease and protect against other diabetes complications are to:.

Most people with type 2 diabetes and kidney disease should be treated with a sodium-glucose co-transporter 2 SGLT2 inhibitor. See 'SGLT2 inhibitors' below. Lifestyle changes — Changing your lifestyle can have a big impact on the health of your kidneys. The following measures are recommended for everyone, but are especially important if you have diabetic kidney disease:.

Blood sugar control — Keeping blood sugars close to normal can help prevent the long-term complications of diabetes mellitus.

See "Patient education: Glucose monitoring in diabetes Beyond the Basics ". A blood test called A1C is also used to monitor blood sugar levels; the result provides an average of blood sugar levels over the last one to three months.

Even small decreases in the A1C lower the risk of diabetes-related complications to some degree. Managing your blood sugar involves lifestyle changes eg, diet and exercise as well as medications. Type 1 diabetes is treated with insulin.

For type 2 diabetes, other medications are often used; some are not recommended for use in people with kidney problems, while others may help slow the progression of kidney disease. Your doctors will work with you to determine what combination of medications is best for you.

Managing high blood pressure — Many people with diabetes have hypertension high blood pressure. Although high blood pressure causes few symptoms, it has two negative effects: it stresses the cardiovascular system and speeds the development of diabetic complications of the kidney and eye.

How Diabetes Causes Kidney Disease Each kidney is made up of millions of tiny filters called nephrons. Tips To Keep Your Kidneys Healthy You can help keep your kidneys healthy by managing your blood sugar, blood pressure, and cholesterol levels.

Physical activity can help prevent kidney disease. Prediabetes and Kidney Disease If you have prediabetes, taking action to prevent type 2 diabetes is an important step in preventing kidney disease. Get Tested for Chronic Kidney Disease Take Care of Your Kidneys Manage High Blood Pressure Living With Diabetes CDC Diabetes on Facebook CDCDiabetes on Twitter.

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Links with this icon indicate that you are leaving the CDC website. The Centers for Disease Control and Prevention CDC cannot attest to the accuracy of a non-federal website. With available protective therapies, a dramatic stabilization of kidney function is likely to be achievable.

See "Diabetic kidney disease: Manifestations, evaluation, and diagnosis", section on 'Natural history'. Of note, people with DKD are at particularly high risk of cardiovascular events, and most have a higher risk of death mostly cardiovascular than developing kidney failure. Cardiovascular protective therapies are therefore also critical.

See "Overview of general medical care in nonpregnant adults with diabetes mellitus", section on 'Reducing the risk of macrovascular disease'. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.

See "Society guideline links: Glomerular disease in adults" and "Society guideline links: Chronic kidney disease in adults" and "Society guideline links: Diabetic kidney disease".

These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest.

The evidence supporting our recommendation is presented separately. See "Goal blood pressure in adults with hypertension", section on 'Patients with chronic kidney disease' and "Goal blood pressure in adults with hypertension", section on 'Patients with diabetes mellitus' and 'Blood pressure control' above.

However, glycemic targets in type 1 diabetes have not been well studied in patients with advanced chronic kidney disease CKD. The approach to target an A1C of 7 percent or less, if tolerated is similar in patients with type 2 diabetes, although fewer supportive data are available than for type 1 diabetes.

The evidence for these approaches is presented elsewhere. See "Glycemic control and vascular complications in type 1 diabetes mellitus" and "Glycemic control and vascular complications in type 2 diabetes mellitus" and 'Glycemic control' above.

See 'Other' above. However, while these drugs are more beneficial than other antihypertensive agents in patients with albuminuric DKD, they do not have clear advantages over calcium channel blockers or diuretics among those without albuminuria.

See 'Severely increased albuminuria: Treat with angiotensin inhibition' above. We also suggest use of an SGLT2 inhibitor in patients with DKD who have lower levels of urine albumin excretion Grade 2B.

The SGLT2 inhibitor is typically added to the patient's existing glucose-lowering regimen since these drugs have weak glucose-lowering effects in patients with reduced kidney function. See 'Type 2 diabetes: Treat with additional kidney-protective therapy' above.

SGLT2 inhibitors increase the risk of genital infections by two- to fourfold primarily vulvovaginal candidiasis and have been associated with Fournier's gangrene in rare cases. SGLT2 inhibitors are not appropriate for use in patients with type 1 diabetes and kidney disease.

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Font Size Small Normal Large. Treatment of diabetic kidney disease. Formulary drug information for this topic. No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Authors: Vlado Perkovic, MBBS, PhD Sunil V Badve, MD, PhD George L Bakris, MD Section Editors: Richard J Glassock, MD, MACP David M Nathan, MD Deputy Editor: John P Forman, MD, MSc Contributor Disclosures.

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Jul 17, aspx Accessed on March 05, Jamerson K, Weber MA, Bakris GL, et al.

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Determinants of severe hypoglycemia complicating type 2 diabetes: the Fremantle diabetes study. J Clin Endocrinol Metab ; Alsahli M, Gerich JE. Hypoglycemia, chronic kidney disease, and diabetes mellitus. Mayo Clin Proc ; Flynn C, Bakris GL. Noninsulin glucose-lowering agents for the treatment of patients on dialysis.

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Collaborative Study Group. Kasiske BL, Kalil RS, Ma JZ, et al. Effect of antihypertensive therapy on the kidney in patients with diabetes: a meta-regression analysis. Ann Intern Med ; Parving HH, Hommel E, Jensen BR, Hansen HP.

Long-term beneficial effect of ACE inhibition on diabetic nephropathy in normotensive type 1 diabetic patients. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. Berl T, Hunsicker LG, Lewis JB, et al.

Impact of achieved blood pressure on cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial. J Am Soc Nephrol ; Pohl MA, Blumenthal S, Cordonnier DJ, et al. Independent and additive impact of blood pressure control and angiotensin II receptor blockade on renal outcomes in the irbesartan diabetic nephropathy trial: clinical implications and limitations.

Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. Parving HH, Lehnert H, Bröchner-Mortensen J, et al.

The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. Patel A, ADVANCE Collaborative Group, MacMahon S, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus the ADVANCE trial : a randomised controlled trial.

Lancet ; Kaplan NM. Vascular outcome in type 2 diabetes: an ADVANCE? Bakris GL, Berkwits M. Trials that matter: the effect of a fixed-dose combination of an Angiotensin-converting enzyme inhibitor and a diuretic on the complications of type 2 diabetes.

Barnett AH, Bain SC, Bouter P, et al. Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. ONTARGET Investigators, Yusuf S, Teo KK, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. Mann JF, Schmieder RE, McQueen M, et al.

Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk the ONTARGET study : a multicentre, randomised, double-blind, controlled trial. Fried LF, Emanuele N, Zhang JH, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy.

Mann JF, Anderson C, Gao P, et al. Dual inhibition of the renin-angiotensin system in high-risk diabetes and risk for stroke and other outcomes: results of the ONTARGET trial.

J Hypertens ; Parving HH, Brenner BM, McMurray JJ, et al. Cardiorenal end points in a trial of aliskiren for type 2 diabetes. American Diabetes Association. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes Diabetes Care ; S Palmer SC, Tendal B, Mustafa RA, et al.

Sodium-glucose cotransporter protein-2 SGLT-2 inhibitors and glucagon-like peptide-1 GLP-1 receptor agonists for type 2 diabetes: systematic review and network meta-analysis of randomised controlled trials.

BMJ ; m Dekkers CCJ, Wheeler DC, Sjöström CD, et al. Effects of the sodium-glucose co-transporter 2 inhibitor dapagliflozin in patients with type 2 diabetes and Stages 3b-4 chronic kidney disease. Nephrol Dial Transplant ; Salah HM, Al'Aref SJ, Khan MS, et al. Effect of sodium-glucose cotransporter 2 inhibitors on cardiovascular and kidney outcomes-Systematic review and meta-analysis of randomized placebo-controlled trials.

Am Heart J ; Gerstein HC, Sattar N, Rosenstock J, et al. Cardiovascular and Renal Outcomes with Efpeglenatide in Type 2 Diabetes. Dave CV, Kim SC, Goldfine AB, et al. Risk of Cardiovascular Outcomes in Patients With Type 2 Diabetes After Addition of SGLT2 Inhibitors Versus Sulfonylureas to Baseline GLP-1RA Therapy.

Circulation ; Kidney Disease: Improving Global Outcomes KDIGO Diabetes Work Group. KDIGO Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.

Kidney Int ; S1. de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association ADA and Kidney Disease: Improving Global Outcomes KDIGO. Rossing P, Caramori ML, Chan JCN, et al. Executive summary of the KDIGO Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease: an update based on rapidly emerging new evidence.

Heerspink HJ, Perkins BA, Fitchett DH, et al. Sodium Glucose Cotransporter 2 Inhibitors in the Treatment of Diabetes Mellitus: Cardiovascular and Kidney Effects, Potential Mechanisms, and Clinical Applications. Heerspink HJL, Kosiborod M, Inzucchi SE, Cherney DZI.

Renoprotective effects of sodium-glucose cotransporter-2 inhibitors. Neuen BL, Young T, Heerspink HJL, et al. SGLT2 inhibitors for the prevention of kidney failure in patients with type 2 diabetes: a systematic review and meta-analysis. Lancet Diabetes Endocrinol ; Perkovic V, Jardine MJ, Neal B, et al.

Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy. Zelniker TA, Wiviott SD, Raz I, et al. SGLT2 inhibitors for primary and secondary prevention of cardiovascular and renal outcomes in type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials.

Heerspink HJ, Desai M, Jardine M, et al. Canagliflozin Slows Progression of Renal Function Decline Independently of Glycemic Effects. Wanner C, Inzucchi SE, Lachin JM, et al.

Empagliflozin and Progression of Kidney Disease in Type 2 Diabetes.