Chronic kidney disease (CKD) is defined by abnormalities of kidney structure or function that persist for at least 3 months and is classified by cause, estimated glomerular filtration rate (eGFR), and albuminuria. Modern CKD care in primary care extends beyond blood pressure control and waiting for advanced loss of kidney function before specialty involvement. In appropriate patients, evidence-based pharmacotherapy can reduce the risks of CKD progression, kidney failure, heart failure hospitalization, and cardiovascular events.^1–3

Our core approach to CKD includes:

SGLT2 inhibitors, including dapagliflozin (Farxiga)

Originally developed for type 2 diabetes, sodium-glucose cotransporter 2 (SGLT2) inhibitors such as dapagliflozin and empagliflozin have demonstrated kidney and cardiovascular benefits in appropriately selected patients with CKD, including many patients without diabetes. These medications slow eGFR decline and reduce the risk of clinically important kidney disease progression; dapagliflozin also reduced the combined risk of cardiovascular death or heart failure hospitalization in DAPA-CKD.^2,3

KDIGO recommends an SGLT2 inhibitor for patients with type 2 diabetes, CKD, and an eGFR of at least 20 mL/min/1.73 m². It also recommends an SGLT2 inhibitor for adults with CKD who have an eGFR of at least 20 mL/min/1.73 m² plus a urine albumin-to-creatinine ratio of at least 200 mg/g, or who have heart failure regardless of albuminuria. Treatment may also be considered in selected adults with an eGFR of 20 to 45 mL/min/1.73 m² and lower levels of albuminuria.¹

Product-specific prescribing information still matters. In the United States, initiation of dapagliflozin for CKD is not recommended when eGFR is below 25 mL/min/1.73 m², although it may generally be continued if eGFR subsequently falls below that level. Treatment decisions must also account for volume status, ketoacidosis risk, acute illness, planned surgery, and the underlying cause of CKD.^1,4

RAS blockade, including telmisartan

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ARBs) remain foundational therapy for albuminuric CKD. Renin-angiotensin system blockade reduces albuminuria and lowers the risk of CKD progression, particularly in patients with moderately or severely increased albuminuria. These medications should generally be titrated to the highest approved dose that is tolerated, with blood pressure, serum creatinine, and potassium checked after initiation and dose increases.¹

When an ARB is appropriate, we often use telmisartan because its terminal elimination half-life is approximately 24 hours, supporting consistent once-daily exposure.⁵ Telmisartan has also demonstrated partial peroxisome proliferator-activated receptor gamma activity (PPAR-γ) in experimental studies which may confer additional benefits though most ARBs offer similar kidney protection.^1,6

Renin-angiotensin system blockade and SGLT2 inhibition have complementary evidence and are commonly layered in eligible patients. This combination forms an important foundation of contemporary treatment for albuminuric CKD, provided kidney function, potassium, blood pressure, and volume status are monitored appropriately.^1–3

GLP-1 receptor agonists

For patients with type 2 diabetes and CKD who have an appropriate indication, glucagon-like peptide 1 (GLP-1) receptor agonists can provide glycemic, weight, cardiovascular, and kidney benefits. In the FLOW trial, once-weekly semaglutide reduced the risk of clinically important kidney outcomes and slowed eGFR decline in patients with type 2 diabetes and CKD.⁷

A GLP-1 receptor agonist may be layered with maximally tolerated renin-angiotensin system blockade and an SGLT2 inhibitor when clinically appropriate. Selection should account for cardiovascular disease, glycemic needs, obesity, gastrointestinal tolerability, cost, patient preference, and product-specific contraindications. Evidence supports each medication class, although evidence for every exact multidrug combination and treatment sequence is less extensive than the evidence for the individual therapies.⁸

Finerenone (Kerendia)

Finerenone is a selective, nonsteroidal mineralocorticoid receptor antagonist indicated for adults with CKD associated with type 2 diabetes. In the pooled FIDELITY analysis of FIDELIO-DKD and FIGARO-DKD, finerenone added to maximally tolerated renin-angiotensin system inhibition reduced clinically important cardiovascular and kidney outcomes compared with placebo.^9,11

We consider finerenone for eligible patients with type 2 diabetes, persistent albuminuria despite optimized renin-angiotensin system blockade, an eGFR above 25 mL/min/1.73 m², and an acceptable serum potassium concentration. Current guidance permits finerenone to be added to a renin-angiotensin system inhibitor and an SGLT2 inhibitor when these therapies are indicated and tolerated.^1,8,11

In the CONFIDENCE trial, starting finerenone and empagliflozin together produced a greater short-term reduction in urine albumin-to-creatinine ratio than either medication alone. The trial was not designed to establish that the combination reduces kidney failure, dialysis, cardiovascular events, or mortality more than either agent alone, so those harder outcomes should not yet be claimed.¹⁰

Although finerenone is nonsteroidal and receptor-selective, it can still cause clinically important hyperkalemia. Serum potassium and eGFR should be assessed before treatment, potassium should generally be rechecked approximately 4 weeks after initiation or a dose change, and monitoring should continue periodically. Drug interactions, particularly with strong CYP3A4 inhibitors, must also be reviewed.^1,9,11

A comprehensive, early-treatment strategy

This layered, guideline-based approach can meaningfully slow CKD progression and reduce the risks of kidney failure and cardiovascular complications. It should not be presented as a guarantee that CKD will stop progressing or that dialysis will always be prevented. Outcomes depend on the cause and severity of CKD, albuminuria, comorbidities, treatment tolerance, and adherence.^1,8

We also address modifiable risk factors and supportive care, including individualized blood pressure and glycemic management, smoking cessation, dietary sodium reduction, physical activity, weight management when appropriate, avoidance of nephrotoxins, medication-dose adjustment, and ongoing monitoring of eGFR and albuminuria.^1,8

Nephrology involvement should be based on the underlying diagnosis, eGFR, albuminuria, rate of progression, kidney failure risk, resistant hypertension, electrolyte abnormalities, anemia, acid-base disturbances, and other CKD complications rather than being postponed until kidney function is severely reduced. Our goal is to identify risk early, implement appropriate medical therapy promptly, monitor treatment safely, and preserve kidney function for as long as possible.¹

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References

1. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314. doi:10.1016/j.kint.2023.10.018
2. Heerspink HJL, Stefánsson BV, Correa-Rotter R, et al; DAPA-CKD Trial Committees and Investigators. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-1446. doi:10.1056/NEJMoa2024816
3. EMPA-KIDNEY Collaborative Group. Empagliflozin in patients with chronic kidney disease. N Engl J Med. 2023;388(2):117-127. doi:10.1056/NEJMoa2204233
4. Farxiga (dapagliflozin) prescribing information. AstraZeneca Pharmaceuticals LP. Accessed June 20, 2026.
5. National Library of Medicine. Telmisartan tablet. DailyMed. Accessed June 20, 2026.
6. Benson SC, Pershadsingh HA, Ho CI, et al. Identification of telmisartan as a unique angiotensin II receptor antagonist with selective PPAR-gamma-modulating activity. Hypertension. 2004;43(5):993-1002. doi:10.1161/01.HYP.0000123072.34629.57
7. Perkovic V, Tuttle KR, Rossing P, et al; FLOW Trial Committees and Investigators. Effects of semaglutide on chronic kidney disease in patients with type 2 diabetes. N Engl J Med. 2024;391(2):109-121. doi:10.1056/NEJMoa2403347
8. American Diabetes Association Professional Practice Committee for Diabetes. 11. Chronic kidney disease and risk management: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(suppl 1):S246-S260. doi:10.2337/dc26-S011
9. Agarwal R, Filippatos G, Pitt B, et al; FIDELIO-DKD and FIGARO-DKD Investigators. Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis. Eur Heart J. 2022;43(6):474-484. doi:10.1093/eurheartj/ehab777
10. Agarwal R, Green JB, Heerspink HJL, et al; CONFIDENCE Investigators. Finerenone with empagliflozin in chronic kidney disease and type 2 diabetes. N Engl J Med. 2025;393(6):533-543. doi:10.1056/NEJMoa2410659
11. US Food and Drug Administration. Kerendia (finerenone) prescribing information. Accessed June 20, 2026.