Rapidly changing landscape of diabetic kidney disease management: recent advances and the road ahead

Diabetic kidney disease (DKD) management has advanced rapidly in recent years, with new therapies supplementing established treatments. The cardiorenal benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1RA) and nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) in patients with DKD have been proven in several large randomised controlled trials. Recent studies show that combining SGLT2i, ns-MRA and renin-angiotensin-aldosterone system (RAAS) blockade significantly slows DKD progression compared with using single agents. The concurrent use of four agents, including GLP-1RA, SGLT2i, ns-MRA and RAAS blockade, may confer additional benefits, and a four-pillar approach to managing DKD could become standard therapy in the future. Additional investigational agents, including endothelin receptor antagonists, aldosterone synthesis inhibitors, and Janus kinase 1 and Janus kinase 2 inhibitors, have demonstrated encouraging results in Phase 2 trials. These therapies may offer further treatment options for patients who are unable to use other agents.