Managing type 2 diabetes can become more challenging for people with later-stage kidney disease, but who haven’t had kidney failure. Along with blood sugar and diabetes management, this may include taking steps like eating a renal diet low in protein, sodium, and phosphorus.
If you live with type 2 diabetes and experience stage 4 chronic kidney disease (CKD), this may include making a number of changes in your life to prevent or slow kidney failure.
At this later stage of kidney disease, the kidneys have not failed, but that is a possible risk factor. That risk
Your team of healthcare professionals can help guide you on managing both conditions and making the necessary lifestyle changes to stay healthy.
How are diabetes and kidney health connected?
Kidney disease is one of the most serious complications that many people with diabetes may experience. It’s the
Diabetes-related kidney disease (nephropathy), or DKD, develops in
What is stage 4 chronic kidney disease?Specifically, stage 4 CKD is the final stage before kidney failure.
This means you have an eGFR between 15 and 29. You may also have protein in your urine. It is important to take steps to slow kidney damage and plan ahead for possible treatments.
What steps to take with late-stage CKD and T2D
Here is a look at the steps to take with this stage of CKD and type 2 diabetes.
- Manage blood sugar: To prevent further kidney damage, it is important to keep glucose levels in a tight range. This involves monitoring blood sugars regularly and keeping your A1C in target range, taking diabetes medications as prescribed, and following a diabetes-friendly eating plan you’ve established with your healthcare team.
- Lower blood pressure: Managing high blood pressure is essential in slowing the progression of kidney disease. This may involve both mediation and eating changes. The American Diabetes Association (ADA)’s standards of care recommend a BP of <130/80 mmHg, and reducing blood pressure variability to slow the CKD progression and lower related
cardiovascular risk . - Adjust medications: Due to reduced kidney function, medications may need to be adjusted or changed to prevent further damage. This includes medications for diabetes, blood pressure, and other conditions.
- Modify your eating: A renal diet low in protein, sodium, and phosphorus may be advised. Working with a dietitian can help tailor a diet plan to individual needs and ensure proper nutrition while managing diabetes and CKD.
- Make lifestyle changes: Encouraging lifestyle modifications such as regular exercise, maintaining a healthy weight, quitting smoking, and limiting alcohol consumption can have a positive impact on overall health.
- Learn and find support: It is important to learn what you can about the conditions and their management. You can also find support groups or counseling to help manage the mental health aspects of living with these chronic illnesses.
Each person’s specific management plan will be individualized and may differ from another person’s care plan.
Your doctors and healthcare team are the best to consult on managing both CKD and T2D.
What diabetes changes happen with late-stage CKD?
Your blood sugar levels
However, if you begin dialysis, your blood sugar levels may rise. This happens when the fluid used to filter your blood has higher amounts of sugar, and your need for insulin and other glucose-lowering medications may not work as effectively. Your doctor may adjust your insulin or medication dosages.
What do you eat with stage 4 CKD and T2D?
Eating changes are a significant part of managing later-stage CKD, especially when you live with diabetes.
Both conditions may involve meal plans and eating styles that contain many of the same foods. However, there are some key differences to keep in mind.
For CKD-specific eating, it’s important to avoid or limit certain foods to protect your kidneys.
The Centers for Disease Control and Prevention (CDC)
- Eat less salt and sodium: Your kidneys lose the ability to control your sodium-water balance over time. Less sodium in your eating plan can help lower blood pressure and decrease fluid buildup in your body, which is common in kidney disease. In a week or two, you’ll get used to less salt in your food.
- Fresh, homemade food: This may help you have more control over the amount of sodium in your food. Eat only small amounts of restaurant food and packaged food, which usually have lots of sodium. Look for low sodium (5% or less) on food labels.
- Add flavor: Use herbs, spices, mustard, and flavored vinegars. But don’t use salt substitutes unless your doctor or dietitian says you can. Many are very high in potassium, which you may need to limit.
- Limit phosphorus: This is a mineral that keeps your bones strong and other parts of your body healthy. Your kidneys can’t remove extra phosphorus from your blood as well. Too much weakens bones and can damage your blood vessels, eyes, and heart. Foods high in phosphorus include meats, dairy, beans, nuts, whole-grain bread, and dark sodas.
- Balancing potassium: Finding the right amount keeps your nerves and muscles working well. With CKD, too much potassium can build up in your blood and cause serious heart problems. Oranges, potatoes, tomatoes, whole grain bread, and many other foods are high in potassium. Apples, carrots, and white bread are lower in potassium.
- Protein amounts: More protein than you need makes your kidneys work harder and may make CKD worse. But too little isn’t healthy either. Both animal and plant foods have protein. Your dietitian can help you figure out the right combination and amount of protein to eat.
Eating in late-stage CKD
Food may taste different if you’re on dialysis. This means you may need to eat more foods, particularly protein.
However, because dialysis may cause fluid to build up in your body between treatments, this will mean you’ll want to limit how much fluid you drink.
Also watch for swelling around your eyes or in your legs, arms, or stomach.
What doctors to see
You may need to consult a team of healthcare professionals, including:
- endocrinologist
- nutritionist or dietitian
- nephrologist
- other specialists
Consult your healthcare team for any concerns you have about T2D or CKD, including any changing symptoms or questions you have about treatments.
What medications will you take?
Your doctor may discuss several different medications if you’re diagnosed with both stage 4 CKD and type 2 diabetes. These
- ACE inhibitors: These medications may help slow CKD progression and protect your kidneys.
- ARBs: These can help slow damage to your kidneys and keep them working as long as possible. While they are often prescribed for people with hypertension, your doctor may prescribe them even if you don’t experience high blood pressure.
- Diabetes medications: You may be prescribed medications to help lower your glucose levels, which is even more important with kidney disease. These can include GLP-1s and SGLT-2 inhibitors, which can also help protect your kidneys and possibly slow the progression of CKD.
- Diuretics: These can help with swelling, which is important during CKD because your kidneys may not be able to effectively get rid of salt and water in your body.
- Supplements: These might include calcium and vitamin D supplements to help strengthen your bones.
- Iron: These supplements, or erythropoiesis-stimulating agents (ESAs), may help if you do not have enough red blood cells in your body (anemia).
- nMRAs: Nonsteroidal mineralocorticoid receptor antagonists may also help reduce swelling and prevent further kidney damage
Your doctor may also recommend that you stop taking certain medications that might damage your kidneys, including nonsteroidal anti-inflammatory medications (NSAIDS). These may include aspirin and ibuprofen.
The takeaway
Managing type 2 diabetes can become more challenging for people with later-stage kidney disease, but who haven’t had kidney failure.
Along with blood sugar and diabetes management, this may include taking steps like eating a renal diet low in protein, sodium, and phosphorus.
SOURCES:
Chaudhry K, et al. (2024). Chronic kidney disease in type 2 diabetes: The size of the problem, addressing residual renal risk and what we have learned from the CREDENCE trial.
Chertow GM, et al. (2021). Effects of Dapagliflozin in Stage 4 Chronic Kidney Disease. https://pmc.ncbi.nlm.nih.gov/articles/PMC8729835/
Chou C-L, et al. (2024). Impact of chronic kidney disease and end-stage renal disease on the mid-term adverse outcomes in diabetic patients with cardiovascular diseases.
Chronic kidney disease and risk management: Standards of Care in Diabetes – 2025. (2024). https://diabetesjournals.org/care/article/48/Supplement_1/S239/157554/11-Chronic-Kidney-Disease-and-Risk-Management
Diabetes and kidney disease: What to eat? (2024).
Kidney disease and diabetes. (2024).
Morales J, et al. (2023). Perspectives on Chronic Kidney Disease With Type 2 Diabetes and Risk Management: Practical Viewpoints and a Paradigm Shift Using a Pillar Approach. https://diabetesjournals.org/clinical/article/41/4/553/151475/Perspectives-on-Chronic-Kidney-Disease-With-Type-2
Rout P, et al. (2025). Diabetic nephropathy.
Stage 4 kidney disease. (2025.) https://www.kidneyfund.org/all-about-kidneys/stages-kidney-disease/stage-4-chronic-kidney-disease-ckd-causes-symptoms-and-treatment
Bhandari S, et al. (2023). Renin-angiotensin system inhibition in advanced chronic kidney disease.https://www.nejm.org/doi/10.1056/NEJMoa2210639
Vaidya SR, et al. (2024). Chronic kidney disease.