Section 11:
Chronic Kidney Disease and
Risk Management
Screening for Chronic Kidney Disease (CKD)
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Who? How? How often?
CIRCLE-CHECK Everyone with type 2 diabetes CIRCLE-CHECK Urinary albumin-to-creatinine Annually
CIRCLE-CHECK Everyone with type 1 diabetes ratio (UACR)
for ≥5 years CIRCLE-CHECK Estimated glomerular filtration
rate (eGFR)
Monitoring Established CKD
How? UACR and eGFR. Use the CKD Epidemiology Collaboration’s CKD-EPI Refit equation,
which eliminates race as a variable, for all individuals.
How often? One to four times per year, depending on the stage of the disease
Classification of CKD
Albuminuria categories
Description and range
CKD is classified based on:
A1 A2 A3
• Cause (C)
Normal to mildly Severely
• GFR (G) Moderately increased
increased increased
• Albuminuria (A)
<30 mg/g 30–299 mg/g ≥300 mg/g
<3 mg/mmol 3–29 mg/mmol ≥30 mg/mmol
G1 Normal or high ≥90 Screen 1 Treat 1 Treat and refer 3
Description and range
(mL/min/1.73 m2)
GFR categories
G2 Mildly decreased 60–89 Screen 1 Treat 1 Treat and refer 3
G3a Mildly to moderately decreased 45–59 Treat 1 Treat 2 Treat and refer 3
G3b Moderately to severely decreased 30–44 Treat 2 Treat and refer 3 Treat and refer 3
G4 Severely decreased 15–29 Treat and refer 3 Treat and refer 3 Treat and refer 4+
G5 Kidney failure <15 Treat and refer 4+ Treat and refer 4+ Treat and refer 4+
Low risk (if no other markers of kidney disease, no CKD) Moderately increased risk High risk Very high risk
Risk of CKD progression, frequency of visits, and referral to nephrology according to glomerular filtration rate (GFR) and albuminuria. Numbers in the boxes are the
number of times per year to screen or monitor. Green reflects no evidence of CKD by eGFR or albuminuria. Suggested monitoring of prevalent CKD varies from once
(yellow) to four or more times (deep red) per year. Adapted from de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: a consensus
report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care 2022;45:3075–3090.
Suggested citation: American Diabetes Association Primary Care Advisory Group. 11. Chronic kidney disease and risk management: Standards of Care in
Diabetes—2024 abridged for primary care professionals. Clin Diabetes 2024;42:212–213 (doi: 10.2337/cd24-a011). ©2024 by the American Diabetes Association.
212 DIABETESJOURNALS.ORG/CLINICAL
AMERICAN DIABETES ASSOCIATION
Why Manage CKD?
Decreases risk of Reduces
CKD progression cardiovascular risk
Holistic Approach to Improving Outcomes in People With Diabetes and CKD
Regular
risk factor
reassessment
Smoking (every 3–6
Lifestyle Healthy diet Physical activity Weight management
months)
cessation
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First-line
SGLT2i Metformin RAS inhibitor Moderate- or high-
drug
(Initiate if eGFR ≥20; (if eGFR ≥30) at maximum intensity statin
therapy
continue until dialysis or tolerated dose (if
transplant) HTN*)
Regular reassessment of
glycemia, albuminuria, BP,
CVD risk, and lipids
GLP-1 RA if needed to Nonsteroidal
Additional Dihydropyridine Ezetimibe, PCSK9i,
achieve individualized MRA† if Antiplatelet
risk-based CCB or icosapent ethyl if
glycemic target ACR ≥30 mg/g agent for
therapy and/or diuretic* if indicated based on
and normal clinical ASCVD
needed to achieve ASCVD risk and
potassium
individualized lipids
BP target
Other glucose-lowering Steroidal MRA
drugs if needed to achieve if needed
individualized for resistant T2D only
glycemic target hypertension if
eGFR ≥45 ll patients
A
(T1D and T2D)
eGFR is presented in units of mL/min/1.73 m2. *ACEi or ARB (at maximal tolerated doses) should be first-line therapy for hypertension when albuminuria
is present. Otherwise, dihydropyridine CCB or diuretic can also be considered; all three classes are often needed to attain BP targets. †Finerenone is
currently the only nonsteroidal MRA with proven clinical kidney and cardiovascular benefits. ACEi, ACE inhibitor; ACR, albumin-to creatinine ratio; ARB,
angiotensin receptor blocker; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CCB, calcium channel blocker; CVD, cardiovascular
disease; GLP-1 RA, glucagon-like peptide 1 receptor agonist; HTN, hypertension; MRA, mineralocorticoid receptor antagonist; PCSK9i, proprotein
convertase subtilisin/kexin type 9 inhibitor; RAS, renin- angiotensin system; SGLT2i, sodium–glucose cotransporter 2 inhibitor; T1D, type 1 diabetes;
T2D, type 2 diabetes. Adapted from de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: a consensus report by the
American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care 2022;45:3075–3090.
Clinical Tips
Қ Periodically check serum creatinine and potassium levels when ACE inhibitor, angiotensin receptor blocker (ARB), or
nonsteroidal mineralcorticoid receptor antagonist is used.
Қ Do not discontinue ACE inhibitor or ARB therapy for increases ≤30% increases in serum creatinine in the absence of volume
depletion.
Қ Aim for a urinary albumin reduction ≥30% in people with CKD and urinary albumin ≥300 mg/g to slow CKD progression.
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