Trends in nephrology: from “diabetic kidney disease” to “CKD with risk factor diabetes”

Diabetic kidney disease (DKD) is typically regarded as a linear complication of chronic hyperglycemia, beginning with albuminuria, followed by reduced eGFR, and finally kidney failure.However, this model does not capture the clinical and biological heterogeneity observed in individuals with diabetes.Previous studies have found that 30-40% of patients with diabetes who develop DKD experience a decline in kidney function without albuminuria, rendering albuminuria in the diagnosis of DKD even more difficult.An emerging perspective characterizes "DKD" as "chronic kidney disease (CKD) with risk factor diabetes", providing increased emphasis on the non-diabetic risk factors.Hypertension, dyslipidemia, obesity, inflammation, and advanced age are all important risk factors contributing to CKD progression.While albuminuria remains a strong marker of risk for progression of CKD, cardiovascular disease and mortality, some well-controlled or older patients with diabetes may experience declines in kidney function without albuminuria, also referred to as nonalbuminuric DKD.This illustrates particular forms of vascular and interstitial damage, suggesting that the decline occurs through alternative pathways other than glomerular damage.This changing view is justified by therapy.Sodium-glucose cotransporter 2 inhibitors delay the loss of kidney function independently of albuminuria and exert benefits via hemodynamic and metabolic pathways, while glucagon-like peptide-1 receptor agonists and mineralocorticoid receptor antagonists provide additional, complementary protection through anti-inflammatory and anti-fibrotic actions.