Clinical practice guidelines for management of hyperglycaemia in adults with diabetic kidney disease


  • Janaka Karalliedde King's College London
  • Peter Winocour Consultant Diabetologist, East and North Herts Institute of Diabetes and Endocrinology, East and North Herts NHS Trust, Welwyn Garden City
  • Tahseen Chowdhury
  • Parijat De
  • Andrew H Frankel
  • Rosa Montero
  • Ana Pokrajac
  • Debasish Banerjee
  • Indranil Dasgupta
  • Damian Fogarty
  • Adnan Sharif
  • Mona Wahba
  • Patrick Mark
  • Sagen Zac-Varghese
  • Dipesh Patel
  • Stephen Bain



diabetic kidney disease, management of hyperglycaemia, clinical guideline


A significant percentage of people with diabetes develop chronic kidney disease and diabetes is also a leading cause of end-stage kidney disease (ESKD). The term diabetic kidney disease (DKD) includes both diabetic nephropathy (DN) and diabetes mellitus and chronic kidney disease (DM CKD). DKD is associated with high morbidity and mortality, which are predominantly related to cardiovascular disease.

Hyperglycaemia is a modifiable risk factor for cardiovascular complications and progression of DKD. Recent clinical trials of people with DKD have demonstrated improvement in clinical outcomes with sodium glucose co-transporter-2 (SGLT-2) inhibitors. SGLT-2 inhibitors have significantly reduced progression of DKD and onset of ESKD and these reno-protective effects are independent of glucose lowering. At the time of this update Canagliflozin and Dapagliflozin have been approved for delaying the progression of DKD.

The Association of British Clinical Diabetologists (ABCD) and UK Kidney Association (UKKA) Diabetic Kidney Disease Clinical Speciality Group have undertaken a literature review and critical appraisal of the available evidence to inform clinical practice guidelines for management of hyperglycaemia in adults with DKD. This 2021 guidance is for the variety of clinicians who treat people with DKD, including GPs and specialists in diabetes, cardiology and nephrology.


Buse JB, Wexler DJ, Tsapas A, et al. 2019 Update to: 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 2020;43(2):487–93.

Cosentino F, Grant PJ, Aboyans V, et al. 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2020;41(2):255–323.

de Boer IH, DCCT/EDIC Group, Kidney disease and related findings in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study. Diabetes Care 2014;37(1):24–30.

Lind M, Svensson A-M, Kosiborod M, et al. Glycemic control and excess mortality in type 1 diabetes. N Engl J Med 2014;371(21):1972–82.

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 mellitus: systematic review and meta-analysis. Arch Intern Med 2012;172(10):761–9.

Rodríguez-Gutiérrez R, Montori VM. Glycemic control for patients with type 2 diabetes mellitus: our evolving faith in the face of evidence. Circ Cardiovasc Qual Outcomes 2016;9(5):504–12.

Zoungas S, Arima H, Gerstein HC, et al. 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(6):431–7.

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(5):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(6):1304–7.

Diao JA, Inker LA, Levey AS, Tighiouart H, Powe NR, Manrai AK. In search of a better equation – performance and equity in estimates of kidney function. N Engl J Med 2021;384(5):396–9.

Pilz S, Rutters F, Nijpels G, et al. Insulin sensitivity and albuminuria: the RISC study. Diabetes Care 2014;37(6):1597–603.

Biesenbach G, Rami A, Schmekal B, Eichbauer-Sturm G. Decreased insulin requirement in relation to GFR in nephropathic type 1 and insulin-treated type 2 diabetic patients. Diabet Med 2003;20(8):642–5.

Javier Escalada F, Halimi S, Senior PA, et al. Glycaemic control and hypoglycaemia benefits with insulin glargine 300 U/mL extend to people with type 2 diabetes and mild-to-moderate renal impairment. Diabetes Obes Metab 2018;20(12):2860–8.

Haluzík M, Cheng A, Muller-Wieland D, et al. Differential glycaemic control with basal insulin glargine 300 U/mL versus degludec 100 U/mL according to kidney function in type 2 diabetes: a subanalysis from the BRIGHT trial. Diabetes Obes Metab 2020;22(8):1369–77.

Snyder RW, Berns JS. Reviews: use of insulin and oral hypoglycemic medications in patients with diabetes mellitus and advanced kidney disease: diabetic medication in kidney disease. Semin Dialysis 2004; 17(5):365–70.

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(2):69.

Home P, Mant J, Diaz J, Turner C, Guideline Development Group. Management of type 2 diabetes: summary of updated NICE guidance. BMJ 2008;336(7656):1306–8.

Crowley MJ, Diamantidis C, McDuffie JR, et al. Clinical outcomes of metformin use in populations with chronic kidney disease, congestive heart failure, or chronic liver disease: a systematic review. Ann Intern Med 2017;166(3):191–200.

Lazarus B, Wu A, Shin J-I, et al. Association of metformin use with risk of lactic acidosis across the range of kidney function: a community-based cohort study. JAMA Intern Med 2018;178(7):903–10.

Inzucchi SE, Lipska KJ, Mayo H, Bailey CJ, McGuire DK. Metformin in patients with type 2 diabetes and kidney disease: a systematic review. JAMA 2014;312(24):2668–75.

Monami M, Dicembrini I, Martelli D, Mannucci E. Safety of dipeptidyl peptidase-4 inhibitors: a meta-analysis of randomized clinical trials. Curr Med Res Opin 2011;27(Suppl 3):57–64.

Palmer SC, Tendal B, Mustafa RA, et al. Sodium-glucose cotransporter protein-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists for type 2 diabetes: systematic review and network meta-analysis of randomised controlled trials. BMJ 2021;372:m4573.

Zelniker TA, Wiviott HD, Raz I, et al. SGLT2 inhibitors for primary and secondary prevention of cardiovascular and renal outcomes in type 2 diabetes: a systematic review and meta-analysis of cardiovascular outcome trials. Lancet 2019;393(10166):31–9.

Neuen BL, Young T, Heerspink HJL, et al. SGLT2 inhibitors for the prevention of kidney failure in patients with type 2 diabetes: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2019;7(11):845–54.

Wanner C, Inzucchi SE, Lachin JM, et al. Empagliflozin and progression of kidney disease in type 2 diabetes. N Engl J Med 2016;375(4):323–34.

Cannon CP, Pratley R, Dagogo-J ack S, et al. Cardiovascular outcomes with ertugliflozin in Type 2 diabetes. N Engl J Med 2020;383(15):1425- 1435.

Perkovic V, Jardine MJ, Neal B, et al. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med 2019;380(24):2295–306.

Heerspink HJL, Stefansson BV, Corea-Rotter R, et al. Dapagliflozin in patients with chronic kidney disease. N Engl J Med 2020;383(15):1436–46.

Sattar N, Lee MMY, Kristensen SL, et al. Cardiovascular, mortality, and kidney outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a systematic review and meta-analysis of randomised trials. Lancet Diabetes Endocrinol 2021;9(10):653–62.

Gariani K, de Seigneux S, Moll S. Acute interstitial nephritis after treatment with liraglutide. Am J Kidney Dis 2014;63(2):347.

Gerstein HC, Colhoun HM, Dagenais GR, et al. Dulaglutide and renal outcomes in type 2 diabetes: an exploratory analysis of the REWIND randomised, placebo-controlled trial. Lancet 2019;394(10193):131–8.

Marso SP, Bain SC, Consoli A, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2016; 375(19):1834–44.







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