Patient handout

Diabetic Kidney Disease (DKD)

PRODUCTION

1. Your condition

This handout is for diabetic kidney disease (dkd). Your care team identified this based on: rising uacr ≥30 mg/g in patient with diabetes (kdigo 2022 diabetes-in-ckd).

Other reasons your team may use this plan: declining egfr + diabetes (kdigo 2022 diabetes-in-ckd); diabetic kidney disease on problem list (kdigo 2022); atypical features (rapid cr rise, hematuria + rbc casts, low complement, no retinopathy) → biopsy ndd (kdigo 2022).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
lisinopril	10 mg PO daily, titrate to max tolerated (40 mg)	PO	daily	KDIGO 2022 — max-tolerated ACEi/ARB; titrate to BP <130/80 + minimize albuminuria
losartan	50-100 mg PO daily, titrate to max tolerated	PO	daily	KDIGO 2022 — ARB equivalent first-line if ACEi cough/angioedema
empagliflozin	10 mg PO daily	PO	daily	EMPA-KIDNEY 2023 PMID 36331190 — empagliflozin reduces CKD progression + CV death; KDIGO 2022 Diabetes-in-CKD foundational
dapagliflozin	10 mg PO daily	PO	daily	DAPA-CKD Heerspink NEJM 2020 — alternative SGLT2i; KDIGO 2022
canagliflozin	100 mg PO daily, titrate to 300 mg if eGFR ≥60	PO	daily	CREDENCE Perkovic NEJM 2019 — canagliflozin in DKD with renal primary endpoint
atorvastatin	40 mg PO daily (high-intensity if ASCVD or risk)	PO	daily	ACC/AHA Lipid 2026 — high-intensity statin for DKD + ASCVD risk reduction

Plan: DKD tier ladder — Tier 1 RAS + SGLT2i + statin + BP/A1c (foundational) → Tier 2 finerenone (FIDELIO + FIGARO) → Tier 3 GLP-1 RA (LEADER + FLOW) → Tier 4 transplant/RRT planning (KDIGO 2022 Diabetes-in-CKD)

3. When to call your provider

Contact your care team if any of the following happen:

Rising Cr >30% on RAS → reduce dose; rule out volume loss + nephrotoxin (KDIGO 2022)
K+ >5.5 → reduce MRA/finerenone/RAS; binder (patiromer/SZC) if persistent (KDIGO 2022)
Atypical features (hematuria + RBC casts, low complement, no retinopathy long DM) → biopsy (KDIGO 2022)
Rapid eGFR decline >5/y → workup for accelerated DKD or NDD (KDIGO 2022)
eGFR <30 → transplant evaluation + AVF planning + pre-RRT education (KDIGO 2022)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Rapid progressor — eGFR decline >5 mL/min/y; consider biopsy for accelerated DKD or NDD; intensify tier ladder + transplant evaluation early (KDIGO 2022)
Biopsy-discordant non-diabetic kidney disease — atypical features (rapid Cr rise, hematuria + RBC casts, low C3/C4, no retinopathy with long DM, nephrotic-range new onset) → biopsy (KDIGO 2022)
DKD with concurrent ASCVD — secondary prevention; high-intensity statin + ezetimibe + PCSK9i if needed; SGLT2i + GLP-1 RA add-on (ACC/AHA Lipid 2026; KDIGO 2022)
Pregnancy with DKD — discontinue ACEi/ARB/SGLT2i/finerenone (teratogenic); switch to nifedipine + labetalol; insulin for glycemic control; refer high-risk OB + nephrology (KDIGO 2022)
ESRD DKD — eGFR <15 (G5); transplant evaluation + AVF placement + pre-RRT planning + shared decision-making conservative vs dialysis (KDIGO 2022; KDIGO 2015)

5. Follow-up

q3-6 mo nephrology + endocrinology; transplant evaluation at G4 (eGFR <30); AVF placement 6 mo pre-RRT; pre-RRT immunization + nutrition + psychosocial (KDIGO 2022)

6. Sources

Guideline: KDIGO 2022 Diabetes Management in CKD + RENAAL/IDNT (RAAS) + SGLT2i (CREDENCE, DAPA-CKD) + finerenone (FIDELIO-DKD, FIGARO-DKD) + GLP-1 RA (FLOW, LEADER)