This protocol covers the management of diabetic nephropathy in patients who have both type 2 diabetes mellitus and chronic kidney disease — a combination that directly shapes which treatments are appropriate and how they must be adjusted over time.
The coexistence of type 2 diabetes mellitus and chronic kidney disease defines this treatment situation. Both conditions must be accounted for when selecting therapy, as declining kidney function directly influences the safety and appropriateness of each treatment option.
When insulin therapy is required in this population, a basal insulin analog approach is recommended — selected in part for its favorable hypoglycemia profile in this setting. Dosing is not fixed: it must be actively adjusted and reduced as kidney function declines.
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 the patient requires insulin, basal insulin therapy with insulin analogs is recommended, due to the lower risk of hypoglycemia.
In a CV safety trial (DEVOTE), insulin degludec showed a lower risk of severe hypoglycemia versus glargine U100 in patients with DM2 and high CV risk (including patients with CKD).
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