Top Takeaways for Clinicians from the

10
KDIGO 2020 Clinical Practice Guideline
for Diabetes Management in CKD1

1
Comprehensive care Some
patients
Patients with diabetes and CKD have multisystem disease that requires Antiplatelet
treatment including a foundation of lifestyle intervention (healthy diet, therapies
Most
exercise, no smoking) and pharmacologic risk factor management patients
(glucose, lipids, blood pressure).
SGLT2 RAS
inhibitors blockade
Nutrition intake All

2
patients
Patients should consume a balanced, healthy diet that is high in vegetables,
fruits, whole grains, fiber, legumes, plant-based proteins, unsaturated fats, Blood
Glycemic pressure Lipid
and nuts; and lower in processed meats, refined carbohydrates, and sweet- 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.
Exercise Nutrition Smoking cessation
Glycemic monitoring

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 Physical activity
dialysis), reliability of HbA1c decreases and results should be interpreted Lifestyle therapy Nutrition
with caution. CGM or SMBG may also be useful, especially for treatment Weight loss
associated with risk of hypoglycemia.
Metformin SGLT2 inhibitor
First-line

4
eGFR eGFR Dialysis + eGFR Dialysis
therapy < 45 < 30 < 30
Glycemic targets Reduce dose Discontinue Discontinue Do not initiate Discontinue

Targets for glycemic control should be individualized ranging from

<6.5% to <8.0%, taking into consideration risk factors for hypoglycemia,
GLP-1 receptor agonist
including advanced CKD and type of glucose-lowering therapy. (preferred)
Additional drug therapy as DPP-4 inhibitor Insulin
needed for glycemic control
Sulfonylurea TZD

SGLT2i Alpha-glucosidase inhibitor

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

itable medicatio
re su

6
Mo ns
Metformin GLP1RA GLP1RA
Metformin should be used for patients with T2D and CKD when eGFR is rbidity or other
mo ch
≥30 ml/min/1.73 m2. For such patients, metformin is a safe, effective, and co a
SU, AGI e, Heart High risk ra DPP4i,
nc
inexpensive drug to control blood glucose and reduce diabetes compli- DPP4i, TZD, AGI

ct
e

failure ASCVD
fer

GLP1RA,

eri
insulin,
Pre

stic
cations. TZD eGFR < 15
mL/min/1.73 Potent
insulin

m2 or treatment glucose-lowering
with dialysis
Avoid

7
GLP-1 RA Low cost hypoglycemia
GLP1RA,
SU, TZD,
In patients with T2D and CKD who have not achieved individualized GLP1RA, AGI Weight Avoid DPP4i,
TZD, AGI SU,
DPP4i, loss injections
glycemic targets despite use of metformin and SGLT2i, or who are insulin
insulin
unable to use those medications, a long-acting GLP-1 RA is recommend-
DPP4i, TZD, SU, AGI,
ed as part of the treatment. GLP1RA
oral GLP1RA

SU, insulin, TZD GLP1RA, insulin

8
RAS blockade
Patients with T1D or T2D, hypertension, and albuminuria (persistent ACR
>30 mg/g) should be treated with a RAS inhibitor (ACEi or ARB), titrated Patient factors influencing the selection of glucose-lowering drugs
other than SGLT2i and metformin in T2D and CKD.
to the maximum approved or highest tolerated dose. Serum potassium
and creatinine should be monitored.
Poorly-informed patients Empowered patients
with suboptimal control Register with optimal control

9
Risk assessment
Approaches to management
A team-based and integrated approach to manage these patients should
Goals
focus on regular assessment, control of multiple risk factors, and
structured education in self-management to protect kidney function and Treat to multiple targets
Relay (glycemia, BP, lipids)
reduce risk of complications. Reinforce Use of organ-protective drugs Risk
Recall (RASi, SGLT2i, GLP1RA, statins) stratification
Ongoing support to promote
self-care

10
Research recommendations
There is a paucity of data on optimal management of diabetes in kidney
Review
failure, including dialysis and transplantation, which should be a focus Risk factor
for future studies. control
Uncoordinated care Coordinated care

ACEi, angiotensin-converting enzyme inhibitor; ACR, albumin-creatinine ratio; AGI, alpha-glucosidase inhibitor; ARB, angiotensin II receptor blocker; ASCVD, atherosclerotic cardiovascular
disease; BP, blood pressure; CKD, chronic kidney disease; DPP4i, dipeptidyl peptidase-4 inhibitor; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide-1 receptor agonist;
HbA1c, hemoglobin A1c (glycated hemoglobin); RAS, renin-angiotensin system; RASi, renin-angiotensin system inhibitor; SGLT2i, sodium-glucose cotransporter-2 inhibitor; SMBG, self-monitor-
ing blood glucose; SU, sulfonylurea; T1D, type 1 diabetes; T2D, type 2 diabetes; TZD, thiazolidinedione
1
Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2020;98(4S):S1–S115. Available at https://kdigo.org/guidelines/diabetes-ckd/.