Summary

KDIGO 2022 is a focused update of the 2020 guideline on diabetes management in CKD, with major revisions to Chapter 1 (comprehensive care) and Chapter 4 (glucose-lowering therapies in T2D); chapters on glycemic monitoring/targets, lifestyle, and care delivery remain unchanged. Key updates expand SGLT2i use down to eGFR ≥20 ml/min/1.73 m² and add a new recommendation for nonsteroidal MRA (finerenone) in T2D with albuminuria despite maximally tolerated RAS inhibition. The guideline emphasizes a layered comprehensive approach: lifestyle therapy plus first-line metformin + SGLT2i + RAS inhibitor + statin, with GLP-1 RA and ns-MRA added based on residual risk.

Key Recommendations

Initiate an ACEi or ARB in patients with diabetes, hypertension, and albuminuria, and titrate to the highest tolerated approved dose (1B).
Treat patients with T2D, CKD, and eGFR ≥20 ml/min/1.73 m² with an SGLT2i for kidney and cardiovascular protection (1A); continue even if eGFR subsequently falls below 20 unless dialysis is initiated.
Add a nonsteroidal MRA (finerenone) for T2D with eGFR ≥25 ml/min/1.73 m², normal serum potassium, and persistent albuminuria ≥30 mg/g despite maximally tolerated RAS inhibitor (2A).
Treat patients with T2D, CKD, and eGFR ≥30 ml/min/1.73 m² with metformin as first-line glycemic therapy (1B); discontinue when eGFR <30.
Use a long-acting GLP-1 RA (prioritize agents with proven CV benefit: liraglutide, semaglutide, dulaglutide) when glycemic targets are not met on metformin + SGLT2i, or when those drugs cannot be used (1B).
Monitor glycemic control with HbA1c in patients with diabetes and CKD (1C); recognize reduced reliability at CKD G4–G5 and consider CGM-derived GMI when discordant.
Target an individualized HbA1c of <6.5% to <8.0% in non-dialysis CKD, based on CKD severity, comorbidities, life expectancy, and hypoglycemia risk (1C).
Maintain protein intake at 0.8 g/kg/day for non-dialysis CKD with diabetes (2C); increase to 1.0–1.2 g/kg/day for patients on hemodialysis or peritoneal dialysis.
Restrict dietary sodium to <2 g/day (<5 g NaCl/day) in patients with diabetes and CKD (2C).
Advise at least 150 minutes/week of moderate-intensity physical activity, or as tolerated based on cardiovascular and physical status (1D).
Advise tobacco cessation in all patients with diabetes and CKD who use tobacco products (1D).
Implement structured diabetes self-management education and team-based, integrated multidisciplinary care for all patients with diabetes and CKD (1C / 2B).

Thresholds & Doses

SGLT2i initiation: eGFR ≥20 ml/min/1.73 m²; continue until dialysis or transplant.
Metformin initiation: eGFR ≥30 ml/min/1.73 m²; reduce dose at eGFR <45; discontinue at eGFR <30.
Finerenone dosing: 10 mg daily if eGFR 25–59 ml/min/1.73 m²; 20 mg daily if eGFR ≥60; require baseline serum K⁺ ≤4.8 mmol/l (per trial); hold if K⁺ >5.5 mmol/l, restart when ≤5.0.
Nonsteroidal MRA eligibility: eGFR ≥25 ml/min/1.73 m² and ACR ≥30 mg/g (≥3 mg/mmol).
ACEi/ARB monitoring: check BP, creatinine, K⁺ within 2–4 weeks of initiation/dose change; continue unless creatinine rises >30% within 4 weeks.
Reduce/discontinue ACEi/ARB at eGFR <15 ml/min/1.73 m² for uremic symptoms or uncontrolled hyperkalemia.
HbA1c target: individualized <6.5% to <8.0% (non-dialysis CKD).
HbA1c monitoring frequency: twice yearly if stable; up to 4× yearly if off target or after therapy change.
Protein intake: 0.8 g/kg/day (non-dialysis CKD); 1.0–1.2 g/kg/day (dialysis).
Sodium intake: <2 g/day (<90 mmol/day; <5 g NaCl/day).
Physical activity: ≥150 minutes/week moderate intensity.
Albuminuria categories: A1 <30 mg/g, A2 30–300 mg/g, A3 >300 mg/g.
Monitor vitamin B12 in patients on metformin >4 years.
SGLT2i agents with proven benefit: dapagliflozin 10 mg daily (eGFR ≥25); empagliflozin 10 mg daily; canagliflozin 100 mg daily (eGFR ≥30).
GLP-1 RA dosing examples: dulaglutide 0.75–1.5 mg weekly (eGFR >15); semaglutide 0.5–1 mg weekly SC or 3–14 mg oral; liraglutide 1.2–1.8 mg daily.
BMI threshold for obesity-related kidney risk: >30 kg/m² (>27.5 kg/m² in Asian populations).

Citations

Chapter 1, Recommendation 1.2.1 — ACEi/ARB titration in diabetes with hypertension and albuminuria.
Chapter 1, Recommendation 1.3.1 and Figures 5–7 — SGLT2i in T2D with eGFR ≥20 ml/min/1.73 m².
Chapter 1, Recommendation 1.4.1 and Figures 8–9 — Nonsteroidal MRA (finerenone) eligibility, dosing, and potassium monitoring.
Chapter 1, Recommendation 1.5.1 — Smoking cessation in diabetes and CKD.
Chapter 2, Recommendation 2.1.1 and 2.2.1, Figure 14 — HbA1c monitoring and individualized targets <6.5% to <8.0%.
Chapter 3, Recommendations 3.1.1, 3.1.2, 3.2.1 — Protein, sodium, and physical activity targets.
Chapter 4, Recommendation 4.1.1 and Figure 27 — Metformin in T2D and CKD with eGFR ≥30, dose adjustment guidance.
Chapter 4, Recommendation 4.2.1 and Figures 28–29 — Long-acting GLP-1 RA after metformin/SGLT2i and CKD dose modifications.