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European Respiratory SocietyDiabetology2026advanced

[Diabetic kidney disease (Update 2026) : Guidelines in a collaboration of the Austrian Diabetes Association and the Austrian Society of Nephrology].

Published by Austrian Diabetes Association and Austrian Society of Nephrology

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Summary

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The 2026 update of the Austrian guideline on Diabetic Kidney Disease outlines comprehensive recommendations for screening, diagnosing, and managing renal complications in patients with Type 1 and Type 2 diabetes. It highlights utilizing the Kidney Failure Risk Equation (KFRE) for risk stratification and strongly supports a multifactorial therapeutic approach. Notably, the guideline advocates for integrating novel renoprotective classes, such as SGLT2 inhibitors, GLP-1 receptor agonists, and the non-steroidal mineralocorticoid receptor antagonist Finerenone, emphasizing their ability to delay disease progression and significantly lower cardiovascular and renal risk.

Diabetic Kidney DiseaseDKDDiabetes MellitusKidney Failure Risk EquationKFRESGLT2 inhibitorsGLP-1 receptor agonistsFinerenone

Key Takeaways

  • 1
    Annual screening for albuminuria and eGFR should begin at diagnosis for Type 2 diabetes, and 5 years post-diagnosis for Type 1 diabetes.
  • 2
    The target blood pressure is generally <140/90 mmHg, but stricter (<130/80 mmHg) for patients with albuminuria (>=30 mg/g).
  • 3
    HbA1c target range is typically 6.5-7.5% for advanced CKD and 7.0-8.0% for dialysis patients, individualized based on age and comorbidities.
  • 4
    SGLT2 inhibitors offer renoprotection and should be initiated at eGFR >20 ml/min/1.73m2 and continued until dialysis.
  • 5
    Finerenone is a key treatment for delaying CKD progression in T2D patients with CKD stages G2-4 and persistent albuminuria on standard therapy.
  • 6
    Metformin dosage requires strict modification below an eGFR of 45 ml/min/1.73m2 and is fully contraindicated below 30 ml/min/1.73m2.

Key Recommendations

Diagnostik der diabetischen Nierenerkrankung

  • rec_01

    Bei T1D sollte das jährliche Screening auf Albuminurie 5 Jahre nach Diagnosestellung, bei T2D bereits mit der Diagnosestellung beginnen. Generell wird empfohlen, als Screening nur die Messung der Albumin/Kreatinin-Ratio (UACR) aus dem Spontanharn durchzuführen.

    Screening

Blutdruckeinstellung

  • rec_02

    Der Zielblutdruck bei DKD wird mit <140/90 mmHg angegeben. Bei Vorliegen einer Albuminurie ≥30 mg/g wird ein Zielblutdruck von <130/80 mmHg vorgeschlagen.

    Treatment

Renoprotektive antihyperglykämische Substanzen

  • rec_03

    Eine SGLT-2-Inhibitor-Therapie sollte bei einer eGFR >20 ml/min/1,73m2 begonnen und bis zur Dialysepflichtigkeit fortgeführt werden, um kardiorenoprotektive Effekte zu erhalten.

    Treatment

Therapiebesonderheiten bei nachlassender Nierenfunktion

  • rec_04

    Metformin ist bei einer eGFR <30 ml/min/1,73m2 kontraindiziert; unter 45 ml/min/1,73m2 sollte es nicht neu begonnen werden und die Dosis auf maximal 1000 mg/Tag beschränkt werden.

    Treatment

Mineralokortikoidrezeptorantagonisten-Therapie

  • rec_05

    Eine Finerenon-Therapie kann bei Menschen mit T2D und CKD G2–4 eingesetzt werden, die trotz einer Therapie mit ACE-Hemmer/ARB und SGLT-2-Inhibitor eine persistierende Albuminurie (A2–3) und normale Kaliumwerte aufweisen.

    Treatment

Lipidstoffwechsel

  • rec_06

    Statine werden bei allen Menschen mit Diabetes und nichtdialysepflichtiger CKD empfohlen. LDL-Cholesterin Zielwert ist <55 mg/dl bei Albuminurie und/oder ab CKD G3 oder G4/5 ohne Dialyse.

    Treatment

Scope & Objectives

Clinical Topic

Diabetic Kidney Disease

Objectives

To propose guidelines for the definition, appropriate diagnostics, and therapeutic strategies for diabetic kidney disease (DKD).

Target Patient Population

Individuals with Type 1 and Type 2 diabetes mellitus with renal involvement (diabetic kidney disease).

Diagnostic Criteria

DKD is diagnosed based on a persistent increase in urinary albumin excretion (UACR >= 30 mg/g) and/or reduced eGFR (< 60 ml/min/1.73m2) in the presence of diabetes mellitus and the absence of another primary cause for CKD. Must be confirmed with the '2 out of 3 rule' using morning spot urine over 3 to 6 months.

Target Providers

DiabetologistsNephrologistsGeneral Practitioners

Patient Criteria & Setting

Therapeutic Area

Endocrinology and Nephrology

Guideline Scope

DiagnosisScreeningManagementTreatment

Care Settings

Outpatient ClinicPrimary CareSpecialist Care

Special Populations

Patients with Type 1 DiabetesPatients with Type 2 DiabetesDialysis patients

Safety & Contraindications

Contraindications

  • Metformin is contraindicated if eGFR < 30 ml/min/1.73m2.
  • Dual RAAS blockade is not recommended due to hyperkalemia and acute kidney injury risk.
  • Finerenone should be paused if serum potassium is >= 5.5 mmol/l.

Monitoring Guidance

Patients require 2 to 4 check-ups per year for HbA1c, lipids, UACR, retention parameters, electrolytes, eGFR, and blood pressure. For eGFR <60 ml/min/1.73m2, supplementary testing for blood count, iron status, calcium, phosphate, PTH, Vitamin D, and venous blood gases is mandated.

Authors & Contributors

Harald SourijFelix AbererMarlies AntlangerJohanna BrixDaniel CejkaMartin ClodiRoland EdlingerKathrin EllerSabine HornSusanne KaserAlexandra Kautzky-WillerMichael LeutnerRainer OberbauerMarkus PirklbauerAlexander R. RosenkranzSabine SchmaldienstHarald StinglDavid StroblMarcus Säemann

Guideline Features

Dosing informationFlowcharts includedMultidisciplinary

Learning Context

Difficulty

advanced

Estimated Read Time

30 minutes

Exam Relevance

Criteria for Diabetic Kidney Disease screening and diagnosiseGFR thresholds for Metformin discontinuation and dosage adjustmentCardiorenal benefits and indications of SGLT2 inhibitors and GLP-1 RAsRole and monitoring of Finerenone in DKDBlood pressure and LDL cholesterol targets in DKD

Learning Paths

Diabetic Kidney DiseaseChronic Kidney DiseaseType 1 DiabetesType 2 DiabetesSGLT2 InhibitorsGLP-1 Receptor AgonistsFinerenoneAlbuminuria