Clinical practice guidelines from KDIGO and ADA
| KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease | ADA Standards of Medical Care in Diabetes—2021 | |
| HbA1c target | <6.5% to <8.0% | <7% for many non-pregnant adults, less stringent HbA1c goals (eg, <8%) for patients with limited life expectancy, or where harms outweigh benefits |
| Blood pressure | Not included | <130/80 mm Hg (existing ASCVD or 10-year ASCVD risk≥15%), <140/90 mm Hg (10-year ASCVD risk<15%) |
| Sodium restriction | <2 g/day | <2300 mg/day, as part of a DASH-style eating pattern for patients with blood pressure of >120/80 mm Hg |
| Protein intake | 0.8 g/kg body weight/day for non-dialysis-dependent patients | 0.8 g/kg body weight/day for non-dialysis-dependent patients; consider higher levels of dietary protein intakes for dialysis-dependent patients |
| Physical activity | Moderate-intensity physical activity for >150 min/week or to a level compatible with their cardiovascular and physical tolerance | ≥150 min of moderate-intensity to vigorous-intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity |
| Weight loss | Not included | ≥5% weight loss for most patients with type 2 diabetes who are overweight or obese and are ready to achieve weight loss |
| Tobacco | Cessation of tobacco products | Cessation of tobacco products |
| ACE inhibitor/ARB | ACE inhibitor or ARB for patients with diabetes, hypertension, and albuminuria, titrated to the highest approved dose that is tolerated | ACE inhibitor or ARB recommended for patients with diabetes and hypertension, modestly elevated UACR (30–299 mg/g creatinine), and strongly recommended for those with UACR of ≥300 mg/g and/or eGFR of <60 mL/min/1.73 m2 |
| Metformin | Metformin for patients with DKD and eGFR of >30 mL/min/1.73 m2 | Metformin is the preferred initial pharmacological agent for the treatment of type 2 diabetes; metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin. |
| SGLT2i | SGLT2i for patients with DKD and eGFR of 30 mL/min/1.73 m2 | SGLT2i for patients with DKD with eGFR of ≥30 mL/min/1.73 m2 and UACR of >300 mg/g; SGLT2i additionally for cardiovascular risk reduction with eGFR of ≥30 mL/min/1.73 m2 or UACR of >300 mg/g |
| GLP-1 RA | GLP-1 RA for patients with DKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2i or who are unable to use those medications | GLP-1 RA for patients with CKD who are at increased risk of cardiovascular events to reduce renal endpoints, primarily albuminuria, progression of albuminuria, and cardiovascular events |
| MRA | Not included | Not included |
ADA, American Diabetes Association; ARB, angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; DASH, Dietary Approaches to Stop Hypertension; DKD, diabetic kidney disease; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HbA1c, glycated hemoglobin; KDIGO, Kidney Disease: Improving Global Outcomes; MRA, mineralocorticoid receptor agonist; SGLT2i, sodium–glucose cotransporter-2 inhibitor; UACR, urine albumin-to-creatinine ratio.