Synopsis
Detect diabetic kidney disease early, recognise atypical features, and layer kidney and cardiovascular protection without avoidable treatment harm.
- Diabetic kidney disease is identified by persistent albuminuria, reduced eGFR or both in a person with diabetes after excluding important alternative explanations.
- Measure urine ACR as well as creatinine because substantial albuminuric risk can exist while eGFR remains normal, and non-albuminuric kidney impairment also occurs.
- Confirm a new abnormal ACR when clinically stable; infection, menstruation, exercise, fever, severe hyperglycaemia and decompensated heart failure can cause transient elevation.
- Rapid eGFR decline, active sediment, systemic features, short diabetes duration or proteinuria out of proportion to other microvascular disease should prompt reconsideration of cause.
- Kidney protection is layered: glycaemic individualisation, blood-pressure control, ACE inhibitor or ARB for indicated albuminuria, SGLT2 inhibition where eligible, lipid care and smoking cessation.
- Finerenone is a NICE option for specified adults with stage 3 or 4 albuminuric CKD associated with type 2 diabetes despite optimised standard care, with potassium-led selection and monitoring.
- An early eGFR dip can accompany effective haemodynamic therapy, but excessive decline, hypovolaemia or hyperkalaemia needs prompt review rather than automatic continuation.
- Sick-day and perioperative plans must be medicine-specific; indiscriminate stopping or restarting can create hyperglycaemia, ketoacidosis, fluid overload or loss of protection.
Key red flags
Active urinary sediment, abrupt nephrosis, rapid decline or systemic illness suggests non-diabetic or superimposed kidney disease.
Weakness, arrhythmia, hypotension, oliguria or pulmonary oedema may reflect medicine interaction, acute illness or advanced CKD.
Nausea, abdominal pain, deep breathing and malaise during fasting or illness on an SGLT2 inhibitor require blood ketones despite near-normal glucose.
Investigation priorities
Detect and grade albuminuria using a standard quantitative measure.
Management branches
A person with diabetes attends planned review.
- Measure urine ACR and serum creatinine/eGFR at the interval specified for diabetes type and previous results.
- Repeat a new ACR abnormality under stable conditions and compare eGFR with earlier values to establish persistence and slope.
- Stage combined G and A categories, communicate cardiovascular as well as renal risk, and assign ownership for follow-up.
Key medicines
SGLT2 inhibitor for eligible type 2 diabetes and CKDChoose the licensed product and dose from the current NICE recommendation, local formulary, eGFR indication and SmPC; counsel before initiation rather than extrapolating between agents.Explain genital infection, volume depletion and rare ketoacidosis. Interrupt for major surgery or acute serious illness, monitor blood ketones, and restart only when stable with normal ketones; avoid use for type 1 diabetes outside specialist governance.
FinerenoneUse within NICE TA877 for eligible stage 3 or 4 albuminuric CKD associated with type 2 diabetes after optimised standard care; select and adjust dose using current potassium, eGFR and SmPC rules.Do not start outside potassium and eGFR criteria. Recheck potassium after initiation and changes, review interacting CYP3A4 medicines and other potassium-raising agents, and pause or discontinue through the live algorithm when hyperkalaemia develops.