Redefining Early Diabetic Kidney Disease Management: A Critical Review of Practice Patterns and Missed Opportunities in Real-World Settings

Early diabetic kidney disease (DKD) is a silent yet progressive complication of diabetes and remains a leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) worldwide. Although international guidelines consistently recommend annual screening of urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR), real-world adherence is persistently low. This narrative review synthesizes global and regional evidence - including findings from a cross-sectional study of more than 1,000 patients with diabetes - to highlight gaps between guideline recommendations and clinical practice. Deficiencies in screening are particularly evident in tertiary care settings, reflecting systemic barriers such as fragmented workflows, limited clinician awareness, and inadequate policy incentives. The expanding therapeutic landscape - including renin-angiotensin-aldosterone system (RAAS) inhibitors, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and non-steroidal mineralocorticoid receptor antagonists (nsMRAs) - underscores the importance of early identification to optimize outcomes. Bridging this practice gap requires a coordinated, system-wide approach that integrates electronic health record (EHR) optimization, multidisciplinary collaboration, continuing professional education, and policy alignment to embed kidney health within comprehensive diabetes care. This review highlights the urgent need for implementation research and health-system reforms to achieve guideline-aligned DKD care worldwide.