Treatment of Chronic Kidney Disease in Type 2 Diabetes with Albuminuria

This protocol addresses adults with chronic kidney disease who also have type 2 diabetes and moderately-to-severely increased urinary albumin excretion — a high-risk clinical combination requiring a targeted, evidence-based approach.

Clinical scenario
Type 2 Diabetes

Chronic kidney disease with type 2 diabetes and albuminuria (urine albumin-to-creatinine ratio >30 mg/g, moderately-to-severely increased). Renin-angiotensin system inhibition (ACEi or ARB) is recommended for patients with CKD, diabetes, and this level of albuminuria to reduce kidney and cardiovascular risk.

Treatment approach

When albuminuria persists despite maximum tolerated renin-angiotensin system inhibition, guidelines support addition of a nonsteroidal mineralocorticoid receptor antagonist with proven kidney or cardiovascular benefit — provided serum potassium is within normal limits and eGFR meets the eligibility threshold. Full dosing criteria, eGFR thresholds, and the complete sequenced regimen are in the protocol ›

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.kint.2023.10.018

We recommend starting RASi (ACEi or ARB) for people with CKD and moderately-to-severely increased albuminuria (G1–G4, A2 and A3) with diabetes (1B).

We suggest a nonsteroidal mineralocorticoid receptor antagonist with proven kidney or cardiovascular benefit for adults with T2D, an eGFR >25 ml/min per 1.73 m², normal serum potassium concentration, and albuminuria (>30 mg/g [>3 mg/mmol]) despite maximum tolerated dose of RAS inhibitor (RASi) (2A).

A nonsteroidal MRA may be added to a RASi and an SGLT2i for treatment of T2D and CKD in adults.

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