Natural history and staging
STAGES (Mogensen classification):
- Stage 1 — Hyperfiltration: raised eGFR at diabetes onset
- Stage 2 — Silent: normal ACR, structural damage on biopsy
- Stage 3 — Microalbuminuria: ACR 3-30 mg/mmol
- Stage 4 — Macroalbuminuria/overt: ACR >30 mg/mmol, falling eGFR
- Stage 5 — Kidney failure: dialysis or transplant
TYPICAL TIMELINE (T1DM): 5-10 years to microalbuminuria, 5-10 more to macroalbuminuria, 5-10 more to ESKD without treatment.
T2DM often diagnosed late — kidney damage may already be present at diagnosis.
When to suspect non-diabetic kidney disease
Refer for biopsy if any of:
- Sudden onset of heavy proteinuria
- Rapid eGFR decline (>5 mL/min/year)
- Active urine sediment (red cells, casts)
- Proteinuria without retinopathy in T1DM
- Short duration of diabetes (<5 years in T1DM)
- Systemic features (rash, joint pain, ANCA+)
Up to 30% of diabetics with kidney disease have a non-diabetic cause on biopsy — IgA nephropathy, membranous, FSGS, AIN.
Kidney Vitality is a daily multivitamin developed by a UK Consultant Nephrologist using renal nutrition principles. It contains no added potassium, magnesium, phosphorus or iron, and no herbal blends. See the formulation.
Treatment — the four pillars (2026)
1. RAS BLOCKADE (ACE inhibitor OR ARB):
- Ramipril, lisinopril, perindopril, losartan, irbesartan
- Up-titrate to maximum tolerated dose
- Accept creatinine rise up to 30%
- Stop if hyperkalaemia >6 or AKI
2. SGLT2 Inhibitor
- Dapagliflozin 10 mg or empagliflozin 10 mg daily
- Use down to eGFR 20 (start at any eGFR ≥20)
- Continue after dialysis if tolerated (renal benefit even at low eGFR)
- Sick-day rules (stop in vomiting/dehydration)
3. FINERENONE (Kerendia):
- Non-steroidal mineralocorticoid receptor antagonist
- 10 or 20 mg once daily based on eGFR/K
- Add to ACE/ARB + SGLT2 if ACR still >3, eGFR >25, K <5.0
- FIDELIO-DKD + FIGARO-DKD: reduces progression and CV events
4. GLUCOSE + BP CONTROL:
- HbA1c target individualised (typically 53 mmol/mol; relax to 58-64 in advanced CKD)
- BP target <130/80
- GLP-1 agonist (semaglutide/dulaglutide) if T2DM with CV risk or obesity
LIFESTYLE: salt <6 g/day, smoking cessation, statin (almost all patients), weight management.
Monitoring and complications
ANNUAL MONITORING (all diabetics):
- Urine ACR (early morning sample)
- eGFR
- Dilated retinal screening
- Foot review
- HbA1c every 3-6 months
As CKD Progresses
- PTH, calcium, phosphate, vitamin D (CKD-MBD)
- Iron studies + Hb (anaemia)
- Bicarbonate (acidosis)
- Refer to nephrology when eGFR <30, or ACR >70, or rapid decline
COMPLICATIONS to anticipate:
- Cardiovascular disease — single biggest cause of death; statin + aspirin/clopidogrel if vascular
- Diabetic retinopathy — almost always co-exists
- Neuropathy + foot ulcers
- Hypoglycaemia risk rises as eGFR falls (reduce insulin/sulfonylurea doses)
