Conceptualizing Treatment Strategies for Diabetic Kidney Disease: the Importance of Early Diagnosis and Treatment.

Chronic kidney disease (CKD) attributed to diabetes, termed diabetic kidney disease (DKD), is increasing with the rising global prevalence of diabetes. Patterns of DKD onset and progression have shifted in recent years because of population aging and advances in the treatment of diabetes. Prevention of the onset and progression of micro/macro-albuminuria is possible through comprehensive and strict management of lifestyle, blood glucose, blood pressure, and lipids in people with diabetes and early DKD. Renin-angiotensin system (RAS) inhibitors have also been shown to effectively slow the progression of CKD in people with diabetes and micro/macro-albuminuria. However, the effect of improving kidney outcomes with RAS inhibitors in people with advanced DKD is limited, and the residual risk remains very high. A recent rapid expansion of treatment options include sodium-glucose co-transporter-2 inhibitors, non-steroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists, which have demonstrated additional protective effects for the kidneys when used in addition to the standard therapy with RAS inhibitors, even in people with advanced DKD. Early diagnosis and therapeutic intervention can be expected to delay progression to end-stage kidney failure. This perspective outlines the diagnostic and therapeutic evolution of DKD to date.