Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO)

People with diabetes and chronic kidney disease (CKD) are at high risk for kidney failure, atherosclerotic cardiovascular disease, heart failure, and premature mortality. Recent clinical trials support new approaches to treat diabetes and CKD. The 2022 American Diabetes Association (ADA) Standards of Medical Care in Diabetes and the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease each provide evidence-based recommendations for management. A joint group of ADA and KDIGO representatives reviewed and developed a series of consensus statements to guide clinical care from the ADA and KDIGO guidelines. The published guidelines are aligned in the areas of CKD screening and diagnosis, glycemia monitoring, lifestyle therapies, treatment goals, and pharmacologic management. Recommendations include comprehensive care in which pharmacotherapy that is proven to improve kidney and cardiovascular outcomes is layered on a foundation of healthy lifestyle. Consensus statements provide specific guidance on use of renin-angiotensin system inhibitors, metformin, sodium–glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist. These areas of consensus provide clear direction for implementation of care to improve clinical outcomes of people with diabetes and CKD. People with diabetes and chronic kidney disease (CKD) are at high risk for kidney failure, atherosclerotic cardiovascular disease, heart failure, and premature mortality. Recent clinical trials support new approaches to treat diabetes and CKD. The 2022 American Diabetes Association (ADA) Standards of Medical Care in Diabetes and the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease each provide evidence-based recommendations for management. A joint group of ADA and KDIGO representatives reviewed and developed a series of consensus statements to guide clinical care from the ADA and KDIGO guidelines. The published guidelines are aligned in the areas of CKD screening and diagnosis, glycemia monitoring, lifestyle therapies, treatment goals, and pharmacologic management. Recommendations include comprehensive care in which pharmacotherapy that is proven to improve kidney and cardiovascular outcomes is layered on a foundation of healthy lifestyle. Consensus statements provide specific guidance on use of renin-angiotensin system inhibitors, metformin, sodium–glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist. These areas of consensus provide clear direction for implementation of care to improve clinical outcomes of people with diabetes and CKD. Clinicians and patients refer to clinical practice guidelines to synthesize data and provide expert direction on diagnosis and treatment. Guidelines must be evidence- based, systematic, transparent, and explicit to offer credibility and impact implementation. They must also allow adaptation to local circumstances and provide mechanisms for updates over time. A rapidly expanding number of clinical trials are advancing clinical care in the field of diabetes and chronic kidney disease (CKD). The American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) each follow structured processes to assess these data and develop rigorous, evidence-based guidelines for adults with diabetes and CKD.1American Diabetes AssociationStandards of Medical Care in Diabetes—2022.Diabetes Care. 2022; 45: S1-S264Crossref PubMed Google Scholar,2Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S123Scopus (50) Google Scholar Areas of consensus between the 2 guidelines therefore represent independent agreement on high priority areas of care. The goal of this consensus report was to identify and highlight shared recommendations from the ADA 2022 Standards of Medical Care in Diabetes (hereafter called Standards of Care) and KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease1American Diabetes AssociationStandards of Medical Care in Diabetes—2022.Diabetes Care. 2022; 45: S1-S264Crossref PubMed Google Scholar,2Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S123Scopus (50) Google Scholar. A joint writing group of ADA and KDIGO representatives convened to compare and contrast ADA and KDIGO recommendations. A series of virtual meetings were held from March 2021 through February 2022 to define scope, review published guidelines and supportive evidence, and jointly write and revise the consensus report. Meetings were cochaired by an ADA representative (GB) and a KDIGO representative (IHdB) and supported by both ADA and KDIGO staff. Consensus statements were drafted when recommendations from each organization were aligned and supported by high-quality evidence from randomized clinical trials (ADA/KDIGO CONSENSUS STATEMENTS). These statements do not specify a level of evidence, which can be found in the individual ADA and KDIGO documents. However, all consensus statements were endorsed by both the ADA and KDIGO and represent broad agreement on evidence-based management of adults with diabetes and CKD. •All patients with type 1 diabetes (T1D) or type 2 diabetes (T2D) and CKD should be treated with a comprehensive plan, outlined and agreed by health care professionals and the patient together, to optimize nutrition, exercise, smoking cessation, and weight, upon which are layered evidence-based pharmacologic therapies aimed at preserving organ function and other therapies selected to attain intermediate targets for glycemia, blood pressure (BP), and lipids.•An ACE inhibitor (ACEi) or angiotensin II receptor blocker (ARB) is recommended for patients with T1D or T2D who have hypertension and albuminuria, titrated to the maximum antihypertensive or highest tolerated dose.•A statin is recommended for all patients with T1D or T2D and CKD, moderate intensity for primary prevention of atherosclerotic cardiovascular disease (ASCVD) or high intensity for patients with known ASCVD and some patients with multiple ASCVD risk factors.•Metformin is recommended for patients with T2D, CKD, and estimated glomerular filtration rate (eGFR) ≥30 ml/min/1.73 m2; the dose should be reduced to 1000 mg daily in patients with eGFR 30–44 ml/min/1.73 m2 and in some patients with eGFR 45–59 ml/min/1.73 m2 who are at high risk of lactic acidosis.•A sodium–glucose cotransporter-2 inhibitor (SGLT2i) with proven kidney or cardiovascular benefit is recommended for patients with T2D, CKD, and eGFR ≥20 ml/min/1.73 m2. Once initiated, the SGLT2i can be continued at lower levels of eGFR.•A glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended for patients with T2D and CKD who do not meet their individualized glycemic target with metformin and/or an SGLT2i or who are unable to use these drugs.•A nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) with proven kidney and cardiovascular benefit is recommended for patients with T2D, eGFR ≥25 ml/min/1.73 m2, normal serum potassium concentration, and albuminuria (albumin-to-creatinine ratio [ACR] ≥30 mg/g) despite maximum tolerated dose of renin-angiotensin system (RAS) inhibitor. CKD occurring among people with diabetes is common, morbid, and costly. The International Diabetes Federation estimates that 537 million people were living with diabetes in 2021, with an expected increase to 784 million by the year 2045.3International Diabetes FederationDiabetes facts & figures.https://idf.org/aboutdiabetes/what-is-diabetes/facts-figures.htmlDate accessed: October 2, 2020Google Scholar The prevalence of CKD among people with diabetes is >25%, and it has been estimated that 40% of people with diabetes develop CKD during their lifetime.4Afkarian M. Zelnick L.R. Hall Y.N. et al.Clinical manifestations of kidney disease among US adults with diabetes, 1988–2014.JAMA. 2016; 316: 602-610Crossref PubMed Scopus (546) Google Scholar As the prevalence of diabetes has increased, the prevalence of CKD attributable to diabetes has grown proportionally.4Afkarian M. Zelnick L.R. Hall Y.N. et al.Clinical manifestations of kidney disease among US adults with diabetes, 1988–2014.JAMA. 2016; 316: 602-610Crossref PubMed Scopus (546) Google Scholar Diabetes is the most common cause of kidney failure requiring kidney transplantation or dialysis worldwide.5Levin A. Tonelli M. Bonventre J. et al.ISN Global Kidney Health Summit participantsGlobal kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy.Lancet. 2017; 390: 1888-1917Abstract Full Text Full Text PDF PubMed Scopus (527) Google Scholar In the United States (US), diabetes fueled a marked increase in the prevalence of kidney failure over the last 30 years and now accounts for half of all new cases of kidney failure.6United States Renal Data System2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2020Google Scholar Moreover, CKD markedly amplifies risks of ASCVD, heart failure (HF), cardiovascular death, and all-cause mortality among people with diabetes.7Afkarian M. Sachs M.C. Kestenbaum B. et al.Kidney disease and increased mortality risk in type 2 diabetes.J Am Soc Nephrol. 2013; 24: 302-308Crossref PubMed Scopus (713) Google Scholar,8Fox C.S. Matsushita K. Woodward M. et al.Chronic Kidney Disease Prognosis Consortium. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis.Lancet. 2012; 380: 1662-1673Abstract Full Text Full Text PDF PubMed Scopus (766) Google Scholar In the US, 1 of every 5 adults with diabetes is not aware of their diagnosis.9Centers for Disease Control and PreventionNational Diabetes Statistics Report, 2020. Centers for Disease Control and Prevention, Atlanta, GA2020Google Scholar Awareness of CKD is even lower, with 9 of 10 individuals unaware of having underlying CKD, including 2 of 5 with severe CKD.6United States Renal Data System2020 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2020Google Scholar,10Chu C.D. McCulloch C.E. Banerjee T. et al.Centers for Disease Control and Prevention Chronic Kidney Disease Surveillance Team. CKD awareness among US adults by future risk of kidney failure.Am J Kidney Dis. 2020; 76: 174-183Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar In addition, both diabetes and CKD disproportionately affect racial and ethnic minorities and older adults. Insufficient screening, diagnosis, and awareness impair efforts to implement treatment and improve outcomes and exacerbate racial, socioeconomic, and ethnic disparities. Furthermore, recent population-based data uncovering disparities in access to glucose-lowering agents with proven kidney and cardiovascular benefits further highlight the need for interventions that ensure more equitable access to and use of these pharmacotherapies across racial and ethnic minorities.11Eberly L.A. Yang L. Eneanya N.D. et al.Association of race/ethnicity, gender, and socioeconomic status with sodium-glucose cotransporter 2 inhibitor use among patients with diabetes in the US.JAMA Netw Open. 2021; 4e216139Crossref Scopus (102) Google Scholar In the US, the total estimated cost of diagnosed diabetes in 2017 was $327 billion, including $237 billion in direct medical costs and $90 billion in reduced productivity.12Marathe P.H. Gao H.X. Close K.L. American Diabetes Association Standards of Medical Care in Diabetes 2017.J Diabetes. 2017; 9: 320-324Crossref PubMed Scopus (305) Google Scholar The estimated global direct health expenditure on diabetes in 2019 was $760 billion.13Williams R. Karuranga S. Malanda B. et al.Global and regional estimates and projections of diabetes-related health expenditure: results from the International Diabetes Federation Diabetes Atlas, 9th edition.Diabetes Res Clin Pract. 2020; 162108072Abstract Full Text Full Text PDF Scopus (354) Google Scholar CKD, with and without kidney failure, is a major driver of the cost of diabetes care. Costs of CKD, stroke, and heart disease are additive.14Chen H.Y. Kuo S. Su P.F. et al.Health care costs associated with macrovascular, microvascular, and metabolic complications of type 2 diabetes across time: estimates from a population- based cohort of more than 0.8 million individuals with up to 15 years of follow-up.Diabetes Care. 2020; 43: 1732-1740Crossref PubMed Scopus (23) Google Scholar,15Wan E.Y.F. Chin W.Y. Yu E.Y.T. et al.The impact of cardiovascular disease and chronic kidney disease on life expectancy and direct medical cost in a 10-year diabetes cohort study.Diabetes Care. 2020; 43: 1750-1758Crossref PubMed Scopus (15) Google Scholar CKD is defined as persistent eGFR <60 ml/min/1.73 m2, albuminuria (ACR ≥30 mg/g), or other markers of kidney damage, such as hematuria or structure abnormalities. Importantly, these measurements can vary within individuals over time, and persistence for at least 3 months is therefore required for diagnosis.16Stevens P.E. Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group MembersEvaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline.Ann Intern Med. 2013; 158: 825-830Crossref PubMed Scopus (1818) Google Scholar For most people, CKD is not identified as a result of symptoms; CKD is often diagnosed through routine screening. Both the ADA and KDIGO recommend annual screening of patients with diabetes for CKD17Draznin B. Aroda V.R. Bakris G. et al.American Diabetes Association Professional Practice Committee11. Chronic kidney disease and risk management: Standards of Medical Care in Diabetes—2022.Diabetes Care. 2022; 45: S175-S184PubMed Google Scholar,18Shlipak M.G. Tummalapalli S.L. Boulware L.E. et al.Conference ParticipantsThe case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.Kidney Int. 2021; 99: 34-47Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar (Figure 1). CKD screening should start at diagnosis of T2D because evidence of CKD is often already apparent at this time. For T1D, screening is recommended commencing 5 years after diagnosis, prior to which CKD is uncommon. Screening is underutilized, particularly for albuminuria. In typical practice in the US, less than half of patients with T2D are screened for albuminuria in a given year.19Stempniewicz N. Vassalotti J.A. Cuddeback J.K. et al.Chronic kidney disease testing among primary care patients with type 2 diabetes across 24 U.S. health care organizations.Diabetes Care. 2021; 44: 2000-2009Crossref PubMed Scopus (23) Google Scholar Clinical laboratories routinely report eGFR calculated from serum creatinine and demographic data.20Delgado C. Baweja M. Crews D.C. et al.A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on reassessing the inclusion of race in diagnosing kidney disease.Am J Kidney Dis. 2022; 79: 268-288.e1Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar, 21Hatlen G. Romundstad S. Hallan S.I. The accuracy of predicting cardiovascular death based on one compared to several albuminuria values.Kidney Int. 2014; 85: 1421-1428Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 22Inker L.A. Eneanya N.D. Coresh J. et al.Chronic Kidney Disease Epidemiology CollaborationNew creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749Crossref PubMed Scopus (494) Google Scholar The American Society of Nephrology and National Kidney Foundation advocate using the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, which was generated without inclusion of a term for race and calculates eGFR without regard to race, to estimate glomerular filtration rate (GFR) from creatinine, age, and sex.20Delgado C. Baweja M. Crews D.C. et al.A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on reassessing the inclusion of race in diagnosing kidney disease.Am J Kidney Dis. 2022; 79: 268-288.e1Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar Another CKD-EPI equation that additionally incorporates serum cystatin C increases precision and reduces racial and ethnic bias, offering additional value in screening and for confirmation of low eGFR in appropriate cases.23Chen T.K. Knicely D.H. Grams M.E. Chronic kidney disease diagnosis and management: a review.JAMA. 2019; 322: 1294-1304Crossref PubMed Scopus (458) Google Scholar, 24Hsu C.Y. Yang W. Parikh R.V. et al.CRIC Study InvestigatorsRace, genetic ancestry, and estimating kidney function in CKD.N Engl J Med. 2021; 385: 1750-1760Crossref PubMed Scopus (69) Google Scholar, 25Levey A.S. Stevens L.A. Schmid C.H. et al.CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)A new equation to estimate glomerular filtration rate.Ann Intern Med. 2009; 150: 604-612Crossref PubMed Scopus (16605) Google Scholar Calculation of the ACR in single-voided “spot” urine samples is most convenient to measure albuminuria. Early morning urine specimens are ideal, although samples collected any time of day may be used. ACR has marked variability; therefore, a confirmatory urine sample within 3–6 months is recommended.26Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work GroupKDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.Kidney Int Suppl. 2013; 3: 1-150Abstract Full Text Full Text PDF Scopus (1664) Google Scholar,27KDOQIKDOQI clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease.Am J Kidney Dis. 2007; 49: S12-S154PubMed Google Scholar KDIGO has codified a CKD classification scheme based on eGFR and albuminuria that is endorsed by the ADA.26Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work GroupKDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.Kidney Int Suppl. 2013; 3: 1-150Abstract Full Text Full Text PDF Scopus (1664) Google Scholar In cohort studies, risks of progressive CKD, cardiovascular events, and mortality all increase with categories of increasing albuminuria or decreasing eGFR. Moreover, CKD stage and corresponding risk category can guide frequency of laboratory monitoring, treatment, and referral to nephrology care (Figure 2). A cause of CKD other than diabetes should be considered in the presence of other systemic diseases that cause CKD, when retinopathy is not present (particularly in T1D), or with CKD signs not common to diabetes (e.g., glomerular hematuria, large and abrupt changes in eGFR or albuminuria, or abnormal serology tests). In the absence of such “red flags,” CKD is usually attributed to diabetes and treated accordingly. Ongoing research seeks to define CKD subtypes with more granularity and link novel subtypes to precision treatments.28Townsend R.R. Guarnieri P. Argyropoulos C. et al.TRIDENT Study InvestigatorsRationale and design of the Transformative Research in Diabetic Nephropathy (TRIDENT) Study.Kidney Int. 2020; 97: 10-13Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar,29de Boer I.H. Alpers C.E. Azeloglu E.U. et al.Kidney Precision Medicine ProjectRationale and design of the Kidney Precision Medicine Project.Kidney Int. 2021; 99: 498-510Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar Multimorbidity is common in patients with diabetes and CKD, who are at high risk of CKD progression, cardiovascular events, and premature mortality. Therefore, both the ADA1American Diabetes AssociationStandards of Medical Care in Diabetes—2022.Diabetes Care. 2022; 45: S1-S264Crossref PubMed Google Scholar and KDIGO2Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S123Scopus (50) Google Scholar emphasize the importance of comprehensive, holistic, patient-centered medical care to improve overall patient outcomes. The goals of comprehensive care are to treat the patient as a “whole” person and incorporate coordinated multidisciplinary treatment, structured education to promote self-management, shared-decision making, and primary and secondary prevention of diabetes-related complications, including CKD, ASCVD, and HF.2Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S123Scopus (50) Google Scholar This approach requires treatment directed to optimize lifestyle, pharmacological therapy aimed at preserving organ function, and additional therapies aimed at improving intermediate risk factors such as glycemia, BP, and lipids (Figure 3). With multiple interventions ubiquitously needed to optimize the care of people with diabetes and CKD, it is crucial to avoid therapeutic inertia.30Davies M.J. D’Alessio D.A. Fradkin J. et al.Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).Diabetes Care. 2018; 41: 2669-2701Crossref PubMed Scopus (1668) Google Scholar Most patients with diabetes and CKD have high residual risks of CKD progression and cardiovascular disease despite treatment, and increasing options are available for risk mitigation. Patients may need to be seen frequently to identify and implement multiple therapies, some of which may interact. For example, RAS inhibitors, SGLT2i, and the ns-MRA finerenone all cause initial hemodynamic reductions in GFR. When indicated, such medications may need to be added and adjusted sequentially, with frequent assessments to institute and optimize care in a timely manner. Empowering patients and facilitating multidisciplinary care can help institute and titrate multiple treatments expeditiously. •All patients with T1D or T2D and CKD should be treated with a comprehensive plan, outlined and agreed by health care professionals and the patient together, to optimize nutrition, exercise, smoking cessation, and weight, upon which are layered evidence-based pharmacologic therapies aimed at preserving organ function and other therapies selected to attain intermediate targets for glycemia, BP, and lipids. The ADA and KDIGO guidelines both advocate for patients to take an active role in managing their diabetes and kidney disease and to have a voice in decisions that affect their well-being.2Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S123Scopus (50) Google Scholar,31Draznin B. Aroda V.R. Bakris G. et al.American Diabetes Association Professional Practice CommitteeAmerican Diabetes Association Professional Practice Committee5. Facilitating behavior change and well-being to improve health outcomes: Standards of Medical Care in Diabetes—2022.Diabetes Care. 2022; 45: S60-S82PubMed Google Scholar Education for patients and an integrated approach to treatment is an effective approach for both patients and clinicians. Patients know themselves better than anyone else, and although health care professionals have the medical background, when a patient and health care professional become partners in developing a shared-decision treatment plan the lives of the patients will improve. In addition, the time required by the health care professional in managing the patients care will be reduced. Patient priorities often do not align with healthcare professional priorities. Ideally, health care professionals will question patients about their priorities and together they will establish an agreed upon care program.32Tuttle K.R. Knight R. Appelbaum P.S. et al.Kidney Precision Medicine ProjectIntegrating patient priorities with science by community engagement in the Kidney Precision Medicine Project.Clin J Am Soc Nephrol. 2021; 16: 660-668Crossref PubMed Scopus (13) Google Scholar Ways in which patients can work with their health care professionals to manage their diabetes and CKD include asking questions; becoming educated about diet, physical activity, smoking cessation, glycemic control, and medications; talking to peers and support groups in the diabetes and CKD community; becoming familiar with technology that is available to track progress; and understanding test results in preparation for health care appointments.33Sadusky T. Hurst C. The patient voice in health care decision making: the perspective of people living with diabetes and CKD.Clin J Am Soc Nephrol. 2021; 16: 991-992Crossref PubMed Scopus (3) Google Scholar Diabetes and CKD management is ideal when the health care system model of care includes a multidisciplinary team to assist patients including the patient, physician (or other care provider), and other health care professionals.2Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S123Scopus (50) Google Scholar,34Draznin B. Aroda V.R. Bakris G. et al.American Diabetes Association Professional Practice CommitteeAmerican Diabetes Association Professional Practice Committee4. Comprehensive medical evaluation and assessment of comorbidities: Standards of Medical Care in Diabetes—2022.Diabetes Care. 2022; 45: S46-S59PubMed Google Scholar Both the ADA and KDIGO guidelines emphasize the importance of a team-based integrated approach that engages diabetes care and education specialists, physicians, nurse practitioners, physician assistants, nurses, dietitians, exercise specialists, pharmacists, dentists, podiatrists, and/or mental health professionals in the care of the patient, with multidisciplinary care models representing a key strategy to overcome barriers to effective management of patients with diabetes and CKD (Figure 4). Health care systems should include team-based care for patients and focus on both short- and long-term treatment plans. Lifestyle interventions for the patient must be included in determining an overall plan of care to ensure individual preferences are addressed and goals are established by all team members, especially the patient. Behavioral evaluation should be considered in the initial assessment for all patients with diabetes. In addition, it should be considered in patients who are unable to meet goals in order to determine potential psychosocial barriers to treatment and self-management. Both the ADA and KDIGO guidelines underscore the integral role of medical nutritional therapy, including adequate access to nutritional management from a specialty-trained registered dietitian nutritionist (RD/RDN), for optimal diabetes management (Supplementary Table S1). The ADA and KDIGO guidelines both recommend individualized and balanced diets that are high in vegetables, fruits, and whole grains but are low in refined carbohydrates and sugar-sweetened beverages.1American Diabetes AssociationStandards of Medical Care in Diabetes—2022.Diabetes Care. 2022; 45: S1-S264Crossref PubMed Google Scholar,2Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S123Scopus (50) Google Scholar Both guidelines also recommend a low-sodium diet (KDIGO <2000 mg/day, ADA 1500 to <2300 mg/day), largely to control BP and reduce cardiovascular risk. The ADA and KDIGO guidelines also recommend targeting a dietary protein intake of 0.8 g/kg/day, the same intake recommended by the World Health Organization for the general population. Higher protein intakes confer theoretical risk of enhancing kidney function decline.35Joint WHO/FAO/UNU Expert ConsultationProtein and Amino Acid Requirements in Human Nutrition. World Health Org., Geneva2007Google Scholar KDIGO performed a systematic review of randomized trials and found no conclusive evidence that restriction of dietary protein to levels <0.8 g/kg/day improves kidney or other health outcomes among people with diabetes and CKD.2Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S123Scopus (50) Google Scholar While the ADA and KDIGO are aligned in this regard, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) has somewhat different recommendations, including restricting dietary protein to 0.55–0.60 g/kg/day (or lower with keto acid analog supplementation) for metabolically stable CKD patients without diabetes and to 0.6–0.8 g/kg/day for patients with diabetes and CKD.36Ikizler T.A. Burrowes J.D. Byham-Gray L.D. et al.KDOQI clinical practice guideline for nutrition in CKD: 2020 update.Am J Kidney Dis. 2020; 76: S1-S107Abstract Full Text Full Text PDF PubMed Scopus (537) Google Scholar All recommendations