Expanding the therapy options for diabetic kidney disease

New DAPA-CKD trial analyses have confirmed the outstanding renoprotective benefits of sodium–glucose co-transporter 2 inhibitors, independently of the presence of diabetes or the stage of kidney disease. Moreover, the non-steroidal mineralocorticoid receptor antagonist finerenone provides renal and cardiovascular protection in diabetic kidney disease when combined with renin–angiotensin–aldosterone system inhibitors.

Key advances

• The kidney benefits of dapagliflozin are independent of the presence of diabetes and have been demonstrated in non-diabetic kidney disease; these benefits are greatest in patients with rapid disease progression but extend to patients with slower progression.

• The magnitude of the observed drop in estimated glomerular filtration rate (eGFR) after initiating treatment with a sodium–glucose co-transporter 2 (SGLT2) inhibitor is associated with early reductions in albuminuria, which in turn correlate with a slower rate of eGFR decline.

• The highly selective mineralocorticoid receptor antagonist finerenone improves kidney and cardiovascular outcomes in patients with diabetic kidney disease (DKD); the cardiovascular benefit is mainly driven by reduced hospitalization for heart failure.

• Combining SGLT2 inhibitors and finerenone, in addition to standard of care (including the use of renin–angiotensin–aldosterone system inhibitors) might slow the progressive loss of eGFR in DKD to values similar to those considered to be physiologically associated with ageing.