Managing hyperglycaemia in patients with diabetes and diabetic nephropathy–chronic kidney disease Summary of recommendations 2018


  • Peter Winocour East and North Hertfordshire NHS Trust
  • Stephen C Bain Swansea University, Swansea, UK
  • Tahseen A Chowdhury Royal London Hospital, London, UK
  • Parijat De City Hospital, Birmingham, UK
  • Ana Pokrajac West Hertfordshire Hospitals, UK
  • Damian Fogarty Belfast Health and Social Care Trust, Belfast, UK
  • Andrew Frankel Imperial College Healthcare NHS Trust, London, UK
  • Debasish Banerjee St George’s Hospital, London, UK
  • Mona Wahba St Helier Hospital, Carshalton, UK
  • Indranil Dasgupta Heartlands Hospital, Birmingham, UK



type 1 diabetes, insulin, chronic kidney disease, nephropathy, hypoglycaemia, sulfonylureas, metformin, sodium glucose co-transporter-2 (SGLT-2) inhibitors, pioglitazone, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) analogue


The ABCD Renal Association guidelines on managing hyperglycaemia in patients with diabetes and kidney disease (DM CKD) are evidence based with recommendations graded accordingly. Audit standards and areas for further research are proposed. Glycaemic targets should vary according to the type of diabetes and the stage of kidney disease. All anti-hyperglycaemic agents can be used in DM CKD but dosage will vary according to the degree of renal disease and certain therapies are currently contraindicated in advanced renal disease. Therefore surveillance for changes in renal function is vital to pre-emptive changes in therapy. Certain combination therapies are either inappropriate of illogical in DM CKD and all with DM CKD should be afforded Sick day Guidance to afford temporary withdrawal of certain therapies. Newer classes of anti-hyperglycaemic agents appear to have renal benefits independent of blood glucose lowering effects but these need clarification from additional studies with hard renal outcomes as primary end points, including evaluation in non–DM CKD.


National Institute for Health and Care Excellence (NICE). Type 2 diabetes in adults: management. [NG28]. London: NICE, 2015. (accessed Feb 2018).

Herman WH, Kalyani RR, Wexler DJ, Matthews DR, Inzucchi S. Approaches to glycaemic treatment. Standards of medical care in diabetes – 2016. Diabetes Care 2016;39(Suppl 1):S52–9.

National Kidney Foundation. KDOQI (Kidney Disease Outcomes Quality Initiative) clinical practice guideline for diabetes and CKD: 2012 update. Am J Kidney Dis 2012;60:850–86.

Bilo H, Coentrao L, Couchard C, et al. Clinical practice guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant 2015;30(Suppl 2):1–142.

Shurraw S, Hemmelgam B, Lin M, et al. Association between glycemic control and adverse outcomes in people with diabetes mellitus and chronic kidney disease: a population based cohort study. Arch Intern Med 2011;171:1920–7.

Ruospo M, Saglimbene VM, Palmer SC, et al. Glucose targets for preventing diabetic kidney disease and its progression. Cochrane Database Syst Rev 2017;6:CD010137.

Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977–86.

De Boer IH, for the DCCT /EDIC Research Group. Kidney disease and related findings in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications. Diabetes Care 2014;37:24–30.

Lind M, Svensson AM, Kosiborod M, et al. Glycemic control and excess mortality in type 1 diabetes. N Engl J Med 2014;371:1972–82.

National Institute for Health and Care Excellence (NICE). Type 1 diabetes in adults: diagnosis and management. [NG17]. London: NICE, 2015. (accessed Feb 2018).

Frankel A, Kazempour-Ardebili S, Bedi R, et al. Management of adults with diabetes on the haemodialysis unit: summary of new guidance from the Joint British Diabetes Societies (JBDS) and the Renal Association. Br J Diabetes 2016;16:69–77.

Raja UY, Chan J, Radford E, et al. The prevalence of anaemia in diabetes with stage 3 chronic kidney disease: a retrospective analysis. Br J Diabetes Vasc Dis 2011;11:259–61.

New JP, Aung T, Baker PG, et al. The high prevalence of unrecognized anaemia in patients with diabetes and chronic kidney disease: a population-based study. Diabet Med 2008;25:564–9.

Agarwal R, Light RP. Relationship between glycosylated haemoglobin and blood glucose during progression of chronic disease. Am J Nephrol 2011;34:32–41.

Ng JM, Cooke M, Bhandari S, Atkin SL, Kilpatrick ES. The effect of iron and erythropoietin treatment on the A1C of patients with diabetes and chronic kidney disease. Diabetes Care 2010;33:2310–3.

Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348:383–93.

Gaede P, Oellgaard J, Carstensen B, et al. Years of life gained by multifactorial intervention in patients with type 2 diabetes and microalbuminuria: 21 years follow-up on the Steno-2 randomised trial. Diabetologia 2016;59:2298–307.

Papademetriou V, Lovato L, Doumas M, et al, for the ACCORD Study Group. Chronic kidney disease and intensive glycaemic control increase cardiovascular risk in patients with type 2 diabetes. Kidney Int 2015; 87:649–59.

Ismail-Beigl F, Craven T, Banerji MA, et al, for the ACCORD Trial Group. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet 2010;376:419–30.

Perkovic V, Heerspink HL, Chalmers J, et al, for the ADVANCE Collaborative Group. Intensive glucose control improves kidney outcomes in patients with type 2 diabetes. Kidney Int 2013;83:517–23.

Zoungas S, Chalmers J, Neal B et al, for the ADVANCE Collaborative Group. Follow-up of blood-pressure lowering and glucose control in type 2 diabetes. N Engl J Med 2014;371:1392–406.

Wong MG, Perkovic V, Chalmers J, et al, for the ADVANCE-ON Collaborative Group. Long-term benefits of intensive glucose control for preventing end-stage kidney disease: ADVANCE-ON. Diabetes Care 2016;39: 694–700.

Coca SG, Ismail-Beigi F, Haq N, Krumholz HM, Parikh CR. Role of intensive glucose control in development of renal end points in type 2 diabetes: systematic review and meta-analysis intensive glucose control in type 2 diabetes. Arch Intern Med 2012;172:761–9.

Rodriguez-Gutiérrez R, Montori VM. Glycaemic control for patients with type 2 diabetes mellitus: our evolving faith in the face of evidence. Circ Cardiovasc Qual Outcomes 2016;9:504–12.

Zoungas S, Arima H, Gerstein HC, et al, Collaborators on Trials of Lowering Glucose (CONTROL) Group. Effects of intensive glucose control on microvascular outcomes in patients with type 2 diabetes: a meta-analysis of individual participant data from randomised controlled trials. Lancet Diabetes Endocrinol 2017;5:431–7.

Lo C, Toyama T, Hirakawa Y, et al. Insulin and glucose-lowering agents for treating people with diabetes and chronic kidney disease (Protocol). Cochrane Database of Systematic Reviews 2015(8).

Wanner C, Inzucchi SE, Lachin JM, et al, for the EMPA-REG OUTCOME Investigators. Empagliflozin and progression of kidney disease in type 2 diabetes. N Engl J Med 2016;375:323–34.

Cherney DZI, Zinman B, Inzucchi SE, et al. Effects of empagliflozin on the urinary albumin-to-creatinine ratio in patients with type 2 diabetes and established cardiovascular disease: an exploratory analysis from the EMPA-REG OUTCOME randomised, placebo-controlled trial. Lancet Diabetes Endocrinol 2017;5:610–21.

Marso SP, Daniels GH, Brown-Frandsen K, et al, on behalf of the LEADER trial investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2016;375:311–22.

Marso SP, Bain SC, Consoli A, et al, for the SUSTAIN Investigators. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2016;375:1834–44.

Wang Y, Katzmarzyk PT, Horswell R, Zhao W, Johnson J, Hu G. Comparison of the heart failure risk stratification performance of the CKD-EPI equation and the MDRD equation for estimated glomerular filtration rate in patients with type 2 diabetes. Diabet Med 2016;33:609–20.

Nair S, Mishra V, Hayden K, et al. The four-variable modification of diet in renal disease formula underestimates glomerular filtration rate in obese type 2 diabetic individuals with chronic kidney disease. Diabetologia 2011;54:1304–7.




Most read articles by the same author(s)

1 2 3 > >>