The Australian and New Zealand Society of Nephrology

The Australian and New Zealand Society of Nephrology is a not-for profit organisation representing the interests of health professionals committed to the prevention and treatment of kidney disease. Through the ANZSN, members support a range of research, education and clinical care initiatives to promote evidenced based practice and quality outcomes for patients in Australia, New Zealand and our region.


Do not intensively lower HbA1C<6.5% to <8.0% in patients with early (stage 1-3) chronic kidney disease as intense lowering increases the risk of hypoglycaemia and mortality, noting that the individual target depends on factors such as severity of CKD, macrovascular complications, comorbidities, life expectancy and others

Date reviewed: 7 May 2021

Diabetes mellitus is associated with significant cardiovascular morbidity and mortality and is the leading cause of chronic kidney disease (CKD) worldwide. Type 2 diabetes is also increasing in prevalence. Evidence indicates that tight glycaemic control in diabetic patients results in clinically significant preservation of kidney function. As such, patients with stage 1–3 CKD stemming from type 1 or type 2 diabetes mellitus should aim to achieve a HbA1c target of approximately 6.5% to <8.0%.

Caution is recommended against intensively lowering HbA1c levels below this target range because of proven increased risks of hypoglycaemia and possibly death. While a lower HbA1c target (<6.5% or <7%) may be preferred in some patients, less stringent glycaemic goals (<7.5% or <8%) may be appropriate for others, especially those with a history of hypoglycaemia, long duration of diabetes, advanced atherosclerosis or advanced age/fragility.

SGLT2 inhibitors are first-line therapy for organ protection in patients with CKD (eGFR >= 30 ml/min/1.73m2 and diabetes).

Supporting evidence

de Boer IH, Caramori ML, Chan JCN, Heerspink HJL, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T, Tandon N, Tuttle KR, Wanner C, Wilkens KG, Zoungas S, Lytvyn L, Craig JC, Tunnicliffe DJ, Howell M, Tonelli M, Cheung M, Earley A, Rossing P. Executive summary of the 2020 KDIGO Diabetes Management in CKD Guideline: evidence-based advances in monitoring and treatment. Kidney Int. 2020 Oct;98(4):839-848

KHA-CARI Guideline: Early chronic kidney disease: Detection, prevention and management. Johnson DW, Atai E, Chan M, Phoon RKS, Scott C, Toussaint ND, Turner GL, Usherwood T, Wiggins KJ. Nephrology 2013; 18(5): 340-50

UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352 (9131): 854–65. 35. UKPDS. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).

How this list was made How this list was made

The Australian and New Zealand Society of Nephrology (ANZSN) Clinical Policy and Advisory Committee worked with the RACP, as part of the Evolve Program, to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting, the list was condensed to the top-5 recommendations for reducing low-value practices in nephrology. Dr David Tunnicliffe has been the Lead Fellow on the project.

The list of recommendations was then subject to an extensive review process that involved key College societies with an interest or professional engagement with nephrology as well as health equity. It was then further consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further research and finetuning of the list, which was then finalised and approved by the ANZSN.