Table 1

Clinical practice guidelines from KDIGO and ADA

KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney DiseaseADA 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 pressureNot 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 intake0.8 g/kg body weight/day for non-dialysis-dependent patients0.8 g/kg body weight/day for non-dialysis-dependent patients; consider higher levels of dietary protein intakes for dialysis-dependent patients
Physical activityModerate-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 lossNot included≥5% weight loss for most patients with type 2 diabetes who are overweight or obese and are ready to achieve weight loss
TobaccoCessation of tobacco productsCessation of tobacco products
ACE inhibitor/ARBACE inhibitor or ARB for patients with diabetes, hypertension, and albuminuria, titrated to the highest approved dose that is toleratedACE 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
MetforminMetformin for patients with DKD and eGFR of >30 mL/min/1.73 m2Metformin 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.
SGLT2iSGLT2i for patients with DKD and eGFR of 30 mL/min/1.73 m2SGLT2i 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 RAGLP-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 medicationsGLP-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
MRANot includedNot 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.