Optimize Treatment of CKD in Patients With Diabetes

Patients with chronic kidney disease (CKD) have a much higher rate of hospitalization, especially if they have diabetes.

Use a hospital stay to optimize treatment.

Ensure patients are on an ACEI or ARB to manage BP.

Continue to use metformin to manage diabetes...if eGFR is 30 mL/min/1.73 m^² or above. Then weigh pros and cons of add-ons at discharge.

SGLT2 inhibitors slow CKD progression...and have CV benefits.

But consider downsides...such as volume depletion, genital yeast infections and rare Fournier’s gangrene, and a cost of over $570/month.

Keep in mind, SGLT2 inhibitors can be started down to an eGFR of 20 mL/min/1.73 m^² for CKD and CV benefits...and continued until dialysis starts. But glucose lowering is limited at a low eGFR.

GLP-1 agonists are another option...specifically dulaglutide (Trulicity), liraglutide (Victoza), or semaglutide (Ozempic).

These may slow CKD progression...and also have CV benefits.

Plus they don’t require dose adjustments for kidney impairment.

But GLP-1 agonists have less data for CKD than SGLT2 inhibitors...and are linked with rare gallbladder issues and pancreatitis. They’re also injectable and cost over $900/month.

Finerenone (Kerendia) is a nonsteroidal mineralocorticoid receptor antagonist. Adding it to an optimized ACEI or ARB slows CKD progression and reduces risk of CV events...likely due to reducing heart failure hospitalizations.

But don’t jump to finerenone. It does NOT lower glucose...and it’s still too soon to say if adding it to an SGLT2 inhibitor or GLP-1 agonist is beneficial.

Plus it can cause hyperkalemia...shouldn’t be started if eGFR is below 25 mL/min/1.73 m^²...and costs about $600/month.

If any of these meds are added or titrated at discharge, reinforce close monitoring of electrolytes and kidney function...such as within 1 to 2 weeks.

Review our resource, Diabetes Medications: Cardiovascular and Kidney Impact, for a deeper dive into the evidence.

• Chart: Diabetes Medications: Cardiovascular and Kidney Impact