# Diabetic Kidney Disease (Diabetic Nephropathy) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ADA Standards of Care 2024 · Egyptian National Drug Formulary - Cardiovascular 2024 (atorvastatin monograph) · Egyptian National Drug Formulary - Cardiovascular 2024 (irbesartan monograph) · KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD, Figure 3 · KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Practice Point 1.4.4 · KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Recommendation 4.1.1 and Figures 26 and 27 · KDIGO Clinical Practice Guideline for Diabetes Management in CKD 2022 - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Cardiovascular 2024 (atorvastatin monograph) - Egyptian National Drug Formulary - Cardiovascular 2024 (irbesartan monograph) - KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD, Figure 3 - KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Practice Point 1.4.4 - KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Recommendation 4.1.1 and Figures 26 and 27 - KDIGO Clinical Practice Guideline for Diabetes Management in CKD 2022 - Chronic Kidney Disease - disease-level clinical article (diabetic-kidney-disease-clinical.txt) - Chronic Kidney Disease - disease-level clinical article (diabetic-kidney-disease-full.txt) ## Treatment metadata - Enalapril — 10 mg — oral.solid - Empagliflozin — 10 mg — oral.solid - Metformin — 500 mg — oral.solid - Referral & safety-netting (no drug therapy) - Losartan — 50 mg — oral.solid - Irbesartan — 150 mg — oral.solid - Finerenone — 10 mg — oral.solid - Atorvastatin — 20 mg — oral.solid ## Complete treatment card ```text DIABETIC KIDNEY DISEASE (DIABETIC NEPHROPATHY) Sources: ADA Standards of Care 2024 · Egyptian National Drug Formulary - Cardiovascular 2024 (atorvastatin monograph) · Egyptian National Drug Formulary - Cardiovascular 2024 (irbesartan monograph) · KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD, Figure 3 · KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Practice Point 1.4.4 · KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Recommendation 4.1.1 and Figures 26 and 27 · KDIGO Clinical Practice Guideline for Diabetes Management in CKD 2022 Review status: REVIEWED against Egyptian National Drug Formulary - Cardiovascular 2024 (atorvastatin monograph), Egyptian National Drug Formulary - Cardiovascular 2024 (irbesartan monograph), KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD, Figure 3, KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Practice Point 1.4.4, KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Recommendation 4.1.1 and Figures 26 and 27, KDIGO Clinical Practice Guideline for Diabetes Management in CKD 2022, Chronic Kidney Disease - disease- level clinical article (diabetic-kidney-disease-clinical.txt), Chronic Kidney Disease - disease-level clinical article (diabetic- kidney-disease-full.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (9) - Early chronic kidney disease is silent; symptoms typically appear only at stage 4 or 5 - Nausea, vomiting, and loss of appetite are reported as the disease advances [nausea · poor appetite · vomiting] - Fatigue, weakness, and disturbed sleep occur in advanced disease [fatigue] - Reduced urine output and diminished mental sharpness may develop - Muscle cramps and swelling of the feet and ankles may occur [muscle cramps] - Persistent itching (pruritus) is a reported complaint [itching] - Chest pain can arise from uremic pericarditis [chest pain] - Breathlessness can result from pulmonary edema caused by fluid overload [breathlessness · oedema] - Hypertension is a reported feature [hypertension] SIGNS - what you find (6) - Skin pigmentation changes may be visible on exam - Scratch marks from chronic itching may be seen on the skin [itching] - A pericardial friction rub can be heard when uremic pericarditis is present [friction rub] - Uremic frost - a fine white crust from urea crystallizing out of sweat - can appear with high BUN - Hyperreflexia or muscle twitching may be found on exam [hyperreflexia] - Hypertensive changes on fundoscopy point to a chronic process TESTS (7) - An eGFR under 60 mL/min per 1.73 m2 prompts a workup for whether the kidney disease is acute or chronic - A normal parathyroid hormone level favors acute kidney injury over chronic kidney disease - Low calcium and high phosphorus levels do not reliably separate acute from chronic kidney disease - Proteinuria is graded A1 to A3 from an early-morning urine albumin-to-creatinine ratio - A dipstick of trace-to-1+ corresponds to albuminuria of 30 to 299 mg/g, and 1+ or greater to over 300 mg/g - Ultrasound showing small kidneys with thin cortex, increased echogenicity, scarring, or cysts points to a chronic process - Biopsy of the kidney is the reference test for pinning down what is driving the disease IF NOT THIS - what else fits (8) - Acute kidney injury is a differential to distinguish from chronic disease - Alport syndrome is a differential to consider - Antiglomerular basement membrane disease is a differential to consider - Diabetic nephropathy is a differential to consider - Multiple myeloma is a differential to consider - Nephrolithiasis is a differential to consider - Rapidly progressive glomerulonephritis is a differential to consider - Renal artery stenosis is a differential to consider Source StatPearls "Chronic Kidney Disease" - disease-level clinical article Status traced to the source above !! MULTI-DRUG REGIMEN - all 2 drugs are given TOGETHER. Not a choice between them. !! the regimen: Enalapril + Empagliflozin Rx: Renin-angiotensin blocker | SGLT2 inhibitor | Glycaemic control | Main treatment | Non- steroidal MRA | Lipid lowering RENIN-ANGIOTENSIN BLOCKER - choose one 1. ENALAPRIL [1 of 2 - GIVE ALL TOGETHER] Adult 5 mg once daily initially (2.5 mg once daily if CrCl <=30 mL/min), titrate up to maximum 40 mg once daily as tolerated - long-term Peds Specialist pediatric endocrinology/nephrology management Source KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD, Figure 3 Why Titrate to the highest dose the patient tolerates - the albuminuria benefit is dose- dependent. Give it with the SGLT2 inhibitor, not instead of one. Caution CONTRAINDICATED in pregnancy. Enalapril is the first-line antihypertensive in diabetic kidney disease with persistent microalbuminuria (UACR >=30 mg/g). Re-check serum creatinine and potassium within 2-4 weeks; an eGFR decline <30% is acceptable. The guideline's ceiling is 40 mg a day, not the 10-20 mg targeted here. Titrate to the highest tolerated dose - under-dosing the blocker is the commonest way this regimen fails. Egypt PRES 10MG 30 TAB. GLOBAL NAPI P... 20.25 EGP (0.68/unit) PRESSLIGHT 10 MG 10 TAB. EL-OBOUR 10.00 EGP (1.00/unit) EZAPRIL 10 MG 30 TABS. MULTI-APEX 54.00 EGP (1.80/unit) 2. LOSARTAN [2nd line] Adult 50 mg once daily, titrate to 100 mg once daily if enalapril is not tolerated due to ACEi cough - long-term Peds Specialist pediatric use only Source KDIGO Clinical Practice Guideline for Diabetes Management in CKD 2022 Why Replaces enalapril when the cough will not settle. Never both - an ACE inhibitor and an ARB together raise potassium and creatinine without adding benefit. The empagliflozin continues either way. Caution DO NOT COMBINE ACE inhibitor and ARB (dual RAS blockade increases AKI and hyperkalemia risk without therapeutic benefit). Contraindicated in pregnancy. Egypt LOSAPOTT 50 MG 14 F.C. TAB. PHAROPHARMA 21.60 EGP (1.54/unit) LOSTAPRESSIN 50 MG 21 F.C. TABS. DELTA PHARMA 33.00 EGP (1.57/unit) AMOSAR 50MG 30 F.C. TABS. AMOUN 51.00 EGP (1.70/unit) LOSARTAN-AMRIYA 50MG 10 TAB. AMRIYA 21.60 EGP (2.16/unit) LOSARMEPHA-50 MG 14 F.C. TABS. SIGMA > ACINO 32.40 EGP (2.31/unit) LOZAPRESS 50MG 14 F.C. TAB. SIGMA 32.40 EGP (2.31/unit) LOSAR 50MG 28 F.C. TAB. UNIPHARMA 82.00 EGP (2.93/unit) COZAAR 50MG 14 TAB. MERCK SHARP &... 74.50 EGP (5.32/unit) 3. IRBESARTAN [2nd line] Adult 150 mg once daily, increased if tolerated to 300 mg once daily. Start at 75-150 mg once daily in patients aged 75 and over or on haemodialysis - Long-term Peds Efficacy and safety in children have not been established. Choice Sourced preference. The Egyptian formulary carries an irbesartan indication that reads as this condition word for word, and 23 products stock it. Source Egyptian National Drug Formulary - Cardiovascular 2024 (irbesartan monograph) Why 23 live products, and the formulary carries an indication that is this condition word for word - 'renal disease in hypertensive type 2 diabetes mellitus' - with its own dose. It is the best-evidenced ARB for diabetic nephropathy specifically. Caution One renin-angiotensin blocker only - irbesartan is an alternative to the enalapril and losartan already listed, never a companion to either. Contraindicated in pregnancy. Contraindicated with aliskiren in diabetes or in moderate-to-severe renal impairment. Correct volume depletion before the first dose. Check creatinine and potassium 1-2 weeks after each dose change; hyperkalaemia is the usual reason to stop. Withhold during dehydrating illness (sick-day rules), particularly alongside the empagliflozin already in this row. Egypt IRBESARTAN 150MG 14 F.C. TABS. MEPACO 16.80 EGP (1.20/unit) IRBESARTAN 150MG 20 TAB. DEBEIKY 26.40 EGP (1.32/unit) IRBETAN 150MG 10 TAB MEMPHIS 14.40 EGP (1.44/unit) ANGIOBLOCK MONO 150 MG 30 F.C. TABS. GLOBAL NAPI PHARMACEUTI... 79.50 EGP (2.65/unit) IRBEFUTAL 150 MG 30 TAB. FUTURE PHARMA... 105.00 EGP (3.50/unit) KANSARTAN 150MG 30 TAB. HIKMA PHARMA ... 105.00 EGP (3.50/unit) RENTENSAR 150 MG 20 SCORED TABS. DEBEIKY 26.40 EGP X-TENSION 150MG 28 SCORED TAB. RAMEDA 40.00 EGP SGLT2 INHIBITOR 4. EMPAGLIFLOZIN [2 of 2 - GIVE ALL TOGETHER] Adult 10 mg once daily in the morning - long-term Peds Not approved under 10 years; specialist management age >=10 Source KDIGO Clinical Practice Guideline for Diabetes Management in CKD 2022 Why Foundational therapy in its own right, not an optional extra. It slows the decline in eGFR by a mechanism the ACE inhibitor does not share, so the two are given together. Caution There is a risk of mycotic genital infections and euglycemic diabetic ketoacidosis (DKA). Initiate if eGFR >=20 mL/min/1.73m2; continue until dialysis or kidney transplantation. Ensure adequate hydration. Egypt EMPAGLIMAX 10 MG 30 F.C. TABS. HIKMA PHARMA 154.50 EGP (5.15/unit) ATCOGLIFLOZIN 10 MG 30 F.C.TABS. ATCO PHARMA 180.00 EGP (6.00/unit) GLIMPACARE 10 MG 30 TABS. MULTICARE 180.00 EGP (6.00/unit) FAGLOZINO 10 MG 30 F.C. TABS. DEBEIKY > INS... 186.00 EGP (6.20/unit) MELLITOFIX 10 MG 30 F.C. TABS. EVA PHARMA 204.00 EGP (6.80/unit) EMPAGLUTECH 10 MG 30 F.C. TABS. MASH PREMIERE 231.00 EGP (7.70/unit) GLEMPOZIN 10 MG 30 F.C. TABS. SIGMA > SOVAL... 240.00 EGP (8.00/unit) JARDIANCE 10 MG 30 F.C. TABS. BOEHRINGER IN... 626.00 EGP (20.87/unit) GLYCAEMIC CONTROL 5. METFORMIN [1st line] Adult 500 mg once or twice daily with meals to start, titrated by 500 mg every 7 days to a usual maintenance of 1000 mg twice daily; maximum 2550 mg/day. Halve the dose if eGFR is 30-44; stop below 30 - long-term Peds Specialist paediatric endocrinology. Diabetic kidney disease is not a primary-care paediatric condition. Source KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Recommendation 4.1.1 and Figures 26 and 27 Why Metformin is KDIGO's first-line glucose-lowering drug down to eGFR 30, and the eGFR thresholds are the reason it belongs on the diabetic kidney disease card rather than only on the type-2-diabetes card. The SGLT2 inhibitor here is given by KDIGO for kidney protection rather than for glucose. Caution The eGFR rules are the point: full dose at 45 and above, half the dose at 30-44, stop below 30, and do not start it below 30. Sick-day rules: hold it during vomiting, diarrhoea, dehydration or sepsis, and before contrast imaging - that is when lactic acidosis happens. Monitor vitamin B12 at least annually on long-term treatment; deficiency is common and causes a neuropathy that gets blamed on the diabetes. Gastrointestinal upset affects up to a quarter of patients; the extended-release form is better tolerated. Take with meals and titrate slowly - a week between steps. Egypt METFORMIN-EL NASR 500MG 200 TAB. EL NASR 26.00 EGP (0.13/unit) DIAPHAGE 500MG 20 TAB. PHAROPHARMA 4.00 EGP (0.20/unit) AMOPHAGE 500MG 30 TAB. AMOUN 10.50 EGP (0.35/unit) CIDOPHAGE 500 MG 10 TAB. CID 11.00 EGP (1.10/unit) GLUCOPHAGE 500 MG 50 F.C.TABS. MINA PHARM > ... 60.00 EGP (1.20/unit) KELVAMET MR 500 MG 30 TABS. BIOMED 54.00 EGP (1.80/unit) ANDOGLYCEMIC XR 500MG 30 EXT. REL. TABS. ANDALOUS PHARMA 24.00 EGP METIANORMIN 500 MG 30 EXT. REL. F.C.TABS. WADI ELNEEL BENTA 54.00 EGP MAIN TREATMENT 6. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Chronic Kidney Disease - disease-level clinical article (diabetic-kidney-disease- clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Avoid nephrotoxic agents including NSAIDs and aminoglycoside antibiotics. RED FLAG - Refer for renal replacement therapy (dialysis access or transplant evaluation) when eGFR drops below 20 mL/min/1.73m2. NON-STEROIDAL MRA 7. FINERENONE [2nd line] Adult 10 mg once daily if eGFR is 25-59 mL/min/1.73m2, or 20 mg once daily if eGFR is 60 or above; uptitrate from 10 mg to 20 mg after 4 weeks if serum potassium is 4.8 mmol/L or less - long-term Peds Not established in children. Source KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease, Practice Point 1.4.4 Why The third pillar of KDIGO's regimen, and it is added on top of the ACE inhibitor and the SGLT2 inhibitor, not instead of either. Practice Point 1.4.2 states a nonsteroidal MRA can be added to a RASi and an SGLT2i. Two brands are marketed in Egypt. Caution Added on top of the renin-angiotensin blocker and the SGLT2 inhibitor. It is not an alternative to either. Only when the albuminuria persists despite the maximum tolerated dose of the ACE inhibitor or ARB - that is the condition KDIGO attaches to the recommendation. Serum potassium must be normal before starting. Do not start if it is above 5.0 mmol/L. Check potassium 4 weeks after starting and after every dose change, then periodically. Hyperkalaemia is the reason this drug is stopped. Not the same as spironolactone. The steroidal MRAs do not have the trial evidence in diabetic kidney disease and cause gynaecomastia; finerenone does not. Do not start below eGFR 25 mL/min/1.73m2. Egypt FINOXLAB 10 MG 20 F.C.TABS. P & C LABS 810.00 EGP (40.50/unit) KERENDIA 10 MG 28 F.C. TABS. BAYER AG 2600.00 EGP (92.86/unit) LIPID LOWERING - give alongside 8. ATORVASTATIN [add-on - not a substitute] Adult 20 mg once daily for primary prevention, increased if needed; 80 mg once daily if there is established cardiovascular disease - long-term Peds The formulary's paediatric atorvastatin dose from 10 years is for familial hypercholesterolaemia, a different indication. Diabetic kidney disease is not a paediatric primary-care condition. Source Egyptian National Drug Formulary - Cardiovascular 2024 (atorvastatin monograph) Why KDIGO puts a moderate- or high-intensity statin in the first-line drug therapy box of its own management figure for every patient with diabetes and CKD. The patient in front of you is far more likely to die of a myocardial infarction than to reach dialysis, and the statin is the drug that addresses that. Caution Given alongside everything else on this card, not instead of anything - the statin treats the cardiovascular risk, not the kidney. No dose adjustment is needed for renal impairment. Contraindicated in active liver failure and decompensated cirrhosis. Muscle pain with weakness is the symptom to ask about at every review - stop promptly and check creatine kinase if it appears. Interacts with clarithromycin and with the azole antifungals; the dose may need to be held during a short course of either. Egypt ANTICHOL 20 MG 10 F.C. TAB. JEDCO INT. CO... 14.40 EGP (1.44/unit) LIRIMAR 20 MG 10 CAPS. RIVA PHARMA S... 15.00 EGP (1.50/unit) LIPOVAST 20MG 7 F.C.TAB. MISR 11.50 EGP (1.64/unit) SIGMALIP 20 MG 10 F.C.TAB. SIGMA 24.00 EGP (2.40/unit) LIPOSEDRA 20 MG 30 F.C.TABS. DELTA PHARMA ... 111.00 EGP (3.70/unit) ATOR 20 MG 10 F.C.TABS. EIPICO 79.00 EGP (7.90/unit) ATCOLIPOX 20 MG 30 CHEW. TABS. ATCO PHARMA 72.00 EGP HIPOLIXAVAST 20 MG 30 CHEW. TABS. EGPI 127.50 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)