Simultaneous Starting of the 4 Guideline Directed CKD Therapies (RAPID-CKD)

The purpose of this study is to determine if starting all four chronic kidney disease therapies at the same time is safe and effective in patients with Type 2 Diabetes and Chronic Kidney Disease. Study hypothesis states that starting all four recommended kidney medications at the same time is safe and effective in reducing albuminuria, a protein in the urine, without a decline in kidney function or increase in potassium levels compared to starting one medication at a time.

Inclusion Criteria: * Patients aged 18-84 years * eGFR 45 to ≤90 mL/min/1.73 m2 * UACR \>200 mg/g * diagnosis of T2D30 * receiving ≤2 guideline-recommended drug classes irrespective of dose for ≥4 weeks prior to screening * eligible for all 4 drugs * systolic BP (SBP) \>90 mmHg * those willing to provide written informed consent and to adhere to study visits. Exclusion Criteria: * Type 1 diabetes * any known primary non-diabetic kidney disease (i.e., polycystic kidney disease, glomerulonephritis, interstitial nephritis, etc.) * history of kidney transplant * liver disease (i.e., aspartate transaminase or alanine transaminase \>5 times, or bilirubin \>3 times the upper limit of normal) * serum potassium \>5.5 mEq/L at baseline * known hypersensitivity to any study drug * life expectancy \<6 months * active malignancy or infection * brittle diabetes (defined as severe glycemic instability with hospitalization or emergency care for hypoglycemia or hyperglycemia within the past 6 months) * high-risk of hypoglycemia (Clarke or Gold score ≥4)31 * predicted 12-month risk of hypoglycemia related emergency visits or hospitalizations \>5% using the Kaiser Permanente hypoglycemia prediction score32,33 * high dose insulin use (\>1 unit/kg/day).