Glomerular hyperfiltration in diabesity: an overlooked target for early intervention

Glomerular hyperfiltration is a well-recognized early abnormality in diabetes and obesity but remains underappreciated in clinical nephrology. Particularly in the context of "diabesity", the merging of type 2 diabetes and obesity, glomerular hyperfiltration may represent an early and potentially reversible contributor to kidney injury. Despite its strong association with albuminuria and decline in glomerular filtration rate (GFR), hyperfiltration is not included in chronic kidney disease (CKD) staging systems, nor routinely flagged by laboratory systems. The lack of a universally accepted definition, along with the absence of easy-to-use diagnostic tools, contributes to its under recognition. However, recent clinical evidence, including our own prospective studies, highlights the prognostic importance of glomerular hyperfiltration and suggests the need to integrate it into risk stratification frameworks. Here, we advocate for the re-evaluation of hyperfiltration in diabesity as a clinically relevant phenotype, we propose practical approaches to identify it in daily practice, including percentile-based thresholds, protein loading tests, and intra-parenchymal renal resistive index variation, and outline a path toward its clinical recognition and therapeutic targeting.