Diabetic Nephropathy in Advanced Age Patients

Diabetes and chronic kidney disease (CKD) are highly prevalent among those of advanced age, and Diabetes is the leading cause of end-stage kidney disease (ESKD) in those over 60. While diagnosis of CKD in those of advance age is made by the same criteria (estimated glomerular filtration rate, eGFR) and albuminuria (urine Albumin to Creatinine Ratio, UACR), the effects of normal aging upon eGFR make diagnosis difficult especially in the absence of severe albuminuria. It is imperative that advanced age individuals with diabetes and CKD are treated in a multidisciplinary fashion recognizing the multiple comorbidities, and higher sensitivity to medication side effects. Translating recent advances in therapeutics from the general population to the advance age patients is challenging. We propose a guideline-based framework for the management of diabetes in CKD and discuss the pharmacological management with inhibitors of the renin-angiotensin system, sodium-glucose co-transporter two inhibitors (SGLT2i), non-steroidal mineralocorticoids and glucagon-like peptide 1 receptor agonists (GLP1-RA). We review the evidence that the benefits from these newer therapies apply equally to those with advanced age or younger and can be deployed in a multidisciplinary management program for diabetes.