Diabetic kidney disease (DKD) is the most common cause of CKD and ESRD worldwide. The 2022 KDIGO Clinical Practice Guideline for Diabetes Management in CKD, produced with ISN endorsement and published in Kidney International, represents the most comprehensive evidence-based framework for DKD management, addressing glycemic targets, renin-angiotensin system inhibition, SGLT2 inhibitors, GLP-1 receptor agonists, and finerenone in a unified treatment algorithm.
ISN (International Society of Nephrology) has consistently advocated for integrated management approaches that address both glycemic and non-glycemic risk factors in DKD. The DCCT and UKPDS trials established that intensive glycemic control prevents the onset of microalbuminuria in type 1 and type 2 diabetes, respectively. Subsequent large trials including ACCORD, ADVANCE, and VADT refined understanding of glycemic targets in patients with established cardiovascular and renal disease.
SGLT2 inhibitors reduce hyperfiltration at the glomerular level and attenuate albuminuria across a spectrum of DKD severity. The combination of CREDENCE (canagliflozin), DAPA-CKD (dapagliflozin), and EMPA-KIDNEY (empagliflozin) trials provides robust evidence for nephroprotection that the International Society of Nephrology has incorporated into advocacy for inclusion of SGLT2 inhibitors on national essential medicines lists in low- and middle-income countries.
Finerenone, a non-steroidal mineralocorticoid receptor antagonist, demonstrated significant reductions in composite kidney and cardiovascular outcomes in patients with type 2 diabetes and CKD across the FIDELIO-DKD trial (Bakris et al., New England Journal of Medicine, 2020) and the FIGARO-DKD trial (Pitt et al., New England Journal of Medicine, 2021). Pooled analyses from the FIDELITY program provided the statistical power to demonstrate mortality benefit, adding an important new drug class to the DKD treatment armamentarium.
ISN has acknowledged the growing complexity of DKD management and has underscored the need for multidisciplinary care. The updated KDIGO heat map for DKD risk stratification, incorporating both eGFR and UACR categories, guides referral decisions and monitoring frequency, and has been widely adopted in ISN member countries as a practical framework for primary care and nephrology-led management of the DKD patient population.