1. Overview & Diagnosis
Chronic Kidney Disease (CKD) is a frequent complication of diabetes, affecting ~50% of people with Type 2 diabetes and 30% of those with Type 1 diabetes. It is a major driver of cardiovascular (CV) mortality.
Definition of CKD:
eGFR:
AND/OR
Albuminuria: Urine Albumin-to-Creatinine Ratio (ACR)
Duration: Abnormalities must persist for > 3 months.
Screening Frequency:
Type 1 Diabetes: Start screening 5 years after diagnosis, then annually.
Type 2 Diabetes: Start screening at diagnosis, then annually.
Method: Random urine ACR + Serum Creatinine (to calculate eGFR).
Diagnosis Confirmation:
A single abnormal ACR is not sufficient. It must be confirmed with 2 out of 3 tests being abnormal over a 3-month period.
False Positives: Exercise, infection, fever, congestive heart failure, menstruation, and acute hyperglycemia can transiently elevate ACR.
2. Comprehensive Management (The "Pillars")
The 2025 guidelines emphasize a multi-pillar approach to delay progression and reduce CV risk.
A. Glycemic & Blood Pressure Control
A1C Target: Individualized (usually ).
Blood Pressure: Target .
B. Pharmacotherapy: The 4 Classes
ACE Inhibitors (ACEi) or ARBs (RAAS Blockade):
Indication: Recommended for people with diabetes, hypertension, and albuminuria (ACR ).
Caution: Monitor creatinine and potassium. A rise in creatinine of up to 30% is acceptable upon initiation; do not stop unless it exceeds this. Do not combine ACEi and ARB.
SGLT2 Inhibitors (Flozins):
Indication: Strongly recommended for adults with Type 2 Diabetes and CKD (eGFR ) to reduce CKD progression and heart failure.
Effect: Reduces intraglomerular pressure.
Initiation: Can be started if eGFR and continued until dialysis is required.
Mineralocorticoid Receptor Antagonists (MRA) – Finerenone:
Indication: For adults with Type 2 Diabetes and CKD (eGFR ) who have persistent albuminuria despite maximizing ACEi/ARB and SGLT2i.
Type: Finerenone is a non-steroidal MRA (unlike spironolactone) and has less risk of side effects but still requires potassium monitoring.
GLP-1 Receptor Agonists:
Role: Recommended for CV risk reduction in T2D and CKD. Can be used if SGLT2i is contraindicated or not tolerated.
Note: Dose adjustment may be needed for renal function depending on the specific agent.
3. Acute Kidney Injury (AKI) & Sick Days
Educating patients on preventing AKI during intercurrent illness is a core CDE competency.
SADMANS Rule: Patients should temporarily stop the following medications when sick (vomiting, diarrhea, unable to hydrate):
S = Sulfonylureas
A = ACE Inhibitors
D = Diuretics / Direct Renin Inhibitors
M = Metformin
A = ARBs
N = NSAIDs
S = SGLT2 Inhibitors
4. Management of Hyperkalemia
Hyperkalemia is a barrier to using life-saving drugs (RAAS inhibitors, MRAs).
Diet: First-line management is dietary restriction of potassium.
Binders: If hyperkalemia persists, consider Potassium Binders (Patiromer or Sodium Zirconium Cyclosilicate) to allow continuation of RAAS blockade rather than stopping the medication.
5. Referral to Nephrology
Referral is indicated if:
Progressive Loss: Rapid decline in eGFR ().
Advanced Disease: eGFR .
Uncertainty: Etiology of kidney disease is unknown.
Management Issues: Unable to control BP or hyperkalemia.
6. 2025 Diabetes Canada Clinical Practice Guidelines Recommendations
Key takeaways from the “Recommendations” section.
Screening: Screen annually with random urine ACR and eGFR [Grade D, Consensus].
SGLT2 Inhibitors: Recommended for patients with T2D and CKD (eGFR ) to reduce progression of kidney disease and CV events [Grade A, Level 1A].
Finerenone: Recommended for patients with T2D and CKD (ACR > 3.0 mg/mmol) with normal potassium, to reduce progression of CKD and CV events [Grade A, Level 1A].
RAAS Blockade: ACEi or ARB should be used in patients with diabetes, hypertension, and clinical albuminuria [Grade A, Level 1].
Hyperkalemia: In patients with hyperkalemia limiting the use of RAAS inhibitors/MRAs, use potassium binders (Patiromer or SZC) to enable continuation of therapy [Grade B, Level 2].