This protocol covers diabetic nephropathy occurring in patients who carry both type 2 diabetes mellitus and chronic kidney disease. The coexistence of these two conditions is central to the treatment strategy, as the degree of remaining kidney function directly shapes which agents are appropriate and how they must be used.
Glycemic management in this population involves selected oral agents whose eligibility is governed by kidney function thresholds. Certain agents are indicated as first choice, while others serve as alternatives when specific contraindications or intolerances are present. The complete agent selection, sequencing, and any required adjustments are set out in the full protocol.
DOI: 10.1016/j.nefro.2024.11.002
Patients with T2D and CKD with an eGFR ≥20 ml/min/1.73 m² should be treated with a sodium-glucose cotransporter-2 inhibitor and continue until end-stage kidney disease (dialysis or kidney transplant).
If patients do not have adequate glycemic control with the SGLT2i/GLP1RA combination (or either contraindication or intolerance to any of them), metformin will be prescribed, as long as GFR > 30. DPP4i are an alternative with a weak antihyperglycemic effect in patients with contraindications or intolerance to GLP-1RA.
Metformin must not be used in patients with eGFR below 30 ml/min/1.73 m² due to the risk of secondary lactic acidosis and must be used cautiously in patients with eGFR between 30 and 44 ml/min/1.73 m², reducing the drug to a maximum of 1000 mg/day.
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