Overview of the management of diabetic kidney disease

ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; eGFR: estimated glomerular filtration rate; SGLT2: sodium-glucose cotransporter 2; Glucagon-like peptide 1 (GLP-1).

* More (versus less) intensive blood pressure goals are typically recommended in patients with diabetes. Refer to UpToDate content on treatment of hypertension in diabetic patients and on goal blood pressure in adults.

¶ Glycemic control targets are typically individualized, but an A1c goal of <7% is frequently recommended. Refer to UpToDate content on glycemic control in patients with type 1 and type 2 diabetes.

Δ Most patients with diabetic kidney disease are at high cardiovascular risk and therefore should be treated with statin therapy. Refer to UpToDate content on low-density lipoprotein cholesterol lowering for primary and secondary, and on medical care of diabetic patients.

◊ After adjusting the patient's therapy and measuring the response at an appropriate time interval, this algorithm can be used again to make further adjustments to the therapeutic regimen (if not already maximized).

§ SGLT2 inhibitors significantly increase the risk of genital infections.

¥ SGLT2 inhibitors reduce the risk of kidney disease progression and end-stage kidney disease in patients with diabetic kidney disease, regardless of the degree of proteinuria. However, patients with severely increased albuminuria (albumin-to-creatinine ratio ≥300 mg/g) are at higher risk for kidney disease progression and end-stage kidney disease and therefore derive a greater absolute benefit from therapy with SGLT2 inhibitors. Patients with normoalbuminuria or moderately increased albuminuria have a lower absolute risk for progression and therefore derive a smaller absolute benefit. Thus, for some patients at lower absolute risk for progression, the benefits and harms of taking an SGLT2 inhibitor may be more closely balanced.