Diabetes management in chronic kidney disease

Red Flags

Severe hypoglycaemia in diabetes with CKD G4–G5 — review insulin and sulfonylurea dose; switch where possible to lower-risk agents (SGLT2 inhibitor, GLP-1 RA, DPP-4 inhibitor)^[1]
Diabetic ketoacidosis on SGLT2 inhibitor (often euglycaemic) — stop drug, IV fluid + insulin; admit; do not restart without specialist review^[1]
Persistent hyperkalaemia >5.5 mmol/L on RAS inhibitor + finerenone — review concurrent agents, dietary potassium, and use potassium binders before withdrawal^[1]
AKI on SGLT2 inhibitor with intercurrent illness — pause drug per sick-day rules; investigate volume status; restart after recovery^[1]

First-line treatment

Interventions

Comprehensive cardio-renal pillar therapy^[1]
All adults with T2DM + CKD: ACEi/ARB + SGLT2 inhibitor + statin + lifestyle change. Add GLP-1 RA for glycaemic and weight benefit; finerenone for residual albuminuria despite RAS + SGLT2
Individualised HbA1c target 6.5–8.0%^[1]
Tighter target for younger, low hypoglycaemia risk, no advanced CKD; relax to 7.5–8.0% in elderly, frail, advanced CKD G4–G5, dialysis, or recurrent hypoglycaemia
Lifestyle and dietary optimisation^[1]
Dietary protein 0.8 g/kg/day in CKD G3–G5 (not on dialysis); sodium <2 g/day; aerobic + resistance exercise; smoking cessation; weight reduction in obesity

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Metformin^[1]	Biguanide	500 mg PO BD; titrate to 2000 mg/day; reduce dose at eGFR 30–45; stop if eGFR <30	Children ≥10 years: 500 mg BD up to 2000 mg/day	First-line for type 2 diabetes; review at every CKD stage transition; lactic acidosis risk with intercurrent illness — sick-day rules
SGLT2 inhibitor (dapagliflozin, empagliflozin, canagliflozin)^[1]	Sodium-glucose cotransporter 2 inhibitor	Dapagliflozin 10 mg PO daily; empagliflozin 10 mg PO daily; canagliflozin 100 mg PO daily	—	Recommend in T2DM + CKD with eGFR ≥20 regardless of HbA1c; expected eGFR dip on initiation; sick-day rules; risk of euglycaemic DKA, genitourinary mycotic infection
GLP-1 receptor agonist (semaglutide, liraglutide, dulaglutide)^[1]	Glucagon-like peptide-1 receptor agonist	Semaglutide 0.25 mg SC weekly start, titrate to 1 mg; liraglutide 0.6 mg SC daily start, titrate to 1.8 mg; dulaglutide 0.75–1.5 mg SC weekly	—	Add when additional glycaemic control or weight loss needed; cardiovascular and renal benefit; pause before elective surgery per local protocol; nausea on initiation
Finerenone^[1]	Non-steroidal mineralocorticoid receptor antagonist	10–20 mg PO once daily by eGFR and potassium; titrate every 4 weeks	—	T2DM + CKD with persistent UACR ≥30 mg/g despite optimal RAS inhibitor + SGLT2 inhibitor; avoid eGFR <25 or K >5.0; FIDELIO-DKD/FIGARO-DKD trials
DPP-4 inhibitor (linagliptin)^[1]	Dipeptidyl peptidase-4 inhibitor	Linagliptin 5 mg PO daily — no dose adjustment in CKD	—	Add-on glycaemic agent in CKD with low hypoglycaemia risk; avoid saxagliptin (HF risk in CKD)
Insulin (basal ± rapid)^[1]	Insulin therapy	Basal insulin (glargine, degludec) 0.1–0.2 U/kg/day start; rapid analogue at meals 0.05 U/kg per meal; reduce dose 25–50% in CKD G4–G5 or dialysis	Per paediatric endocrinology	Required when oral therapy insufficient or contraindicated; CKD reduces insulin clearance — increased hypoglycaemia risk

Metformin^[1]

Biguanide

Adult: 500 mg PO BD; titrate to 2000 mg/day; reduce dose at eGFR 30–45; stop if eGFR <30
Paediatric: Children ≥10 years: 500 mg BD up to 2000 mg/day

First-line for type 2 diabetes; review at every CKD stage transition; lactic acidosis risk with intercurrent illness — sick-day rules

SGLT2 inhibitor (dapagliflozin, empagliflozin, canagliflozin)^[1]

Sodium-glucose cotransporter 2 inhibitor

Adult: Dapagliflozin 10 mg PO daily; empagliflozin 10 mg PO daily; canagliflozin 100 mg PO daily
Paediatric: —

Recommend in T2DM + CKD with eGFR ≥20 regardless of HbA1c; expected eGFR dip on initiation; sick-day rules; risk of euglycaemic DKA, genitourinary mycotic infection

GLP-1 receptor agonist (semaglutide, liraglutide, dulaglutide)^[1]

Glucagon-like peptide-1 receptor agonist

Adult: Semaglutide 0.25 mg SC weekly start, titrate to 1 mg; liraglutide 0.6 mg SC daily start, titrate to 1.8 mg; dulaglutide 0.75–1.5 mg SC weekly
Paediatric: —

Add when additional glycaemic control or weight loss needed; cardiovascular and renal benefit; pause before elective surgery per local protocol; nausea on initiation

Finerenone^[1]

Non-steroidal mineralocorticoid receptor antagonist

Adult: 10–20 mg PO once daily by eGFR and potassium; titrate every 4 weeks
Paediatric: —

T2DM + CKD with persistent UACR ≥30 mg/g despite optimal RAS inhibitor + SGLT2 inhibitor; avoid eGFR <25 or K >5.0; FIDELIO-DKD/FIGARO-DKD trials

DPP-4 inhibitor (linagliptin)^[1]

Dipeptidyl peptidase-4 inhibitor

Adult: Linagliptin 5 mg PO daily — no dose adjustment in CKD
Paediatric: —

Add-on glycaemic agent in CKD with low hypoglycaemia risk; avoid saxagliptin (HF risk in CKD)

Insulin (basal ± rapid)^[1]

Insulin therapy

Adult: Basal insulin (glargine, degludec) 0.1–0.2 U/kg/day start; rapid analogue at meals 0.05 U/kg per meal; reduce dose 25–50% in CKD G4–G5 or dialysis
Paediatric: Per paediatric endocrinology

Required when oral therapy insufficient or contraindicated; CKD reduces insulin clearance — increased hypoglycaemia risk

Safety-net

Sick-day rules — temporarily hold metformin, SGLT2 inhibitor, ACE inhibitor/ARB, finerenone, and reduce insulin during dehydrating illness; restart when eating and drinking normally^[1]
Watch for euglycaemic DKA on SGLT2 inhibitor — nausea, abdominal pain, breathlessness with normal blood glucose; check ketones and seek same-day review^[1]
Carry rapid-acting glucose; teach household members glucagon use if on insulin or sulfonylurea — hypoglycaemia recognition is harder in advanced CKD^[1]

Referral criteria

T2DM + CKD with persistent UACR ≥30 mg/g despite optimal RAS + SGLT2 inhibitorNephrology and consider finerenone^[1]
Recurrent severe hypoglycaemia in CKD on insulin or sulfonylureaDiabetes specialist for therapy switch and continuous glucose monitoring^[1]
eGFR <30 or rapid eGFR decline (>5 mL/min/year)Nephrology^[1]
Pregnancy in T2DM with CKDJoint diabetes, obstetric, and nephrology clinic^[1]

Clinical summary

Glycaemic and cardio-renal protective therapy for adults with type 2 diabetes and CKD; SGLT2 inhibitor + GLP-1 RA + finerenone framework.

References

1.KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (with KDIGO 2024 CKD update) (2022)