The Paradigm Shift in the Management of Diabetic Kidney Disease: A Comprehensive Review of the Four Pillars of Therapy

The global burden of type 2 diabetes mellitus (T2DM) and chronic kidney disease is rapidly on the rise. For nearly two decades, the therapeutic armamentarium for diabetic kidney disease (DKD) limited to rigorous glycemic control and blockade of the renin–angiotensin system (RAS). However, recent advances in understanding the disease have led to a significant shift in the management of DKD. The current “Four Pillars” framework – comprising RAS blockade, sodium glucose cotransporter 2 inhibitors, non-steroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists – represents a transition from treating a single symptom to targeting the holistic pathophysiology of the disease. This review highlights the paradigm shifts in the management of DKD with the advent of the newer drugs. It also discusses the guideline-directed medical therapy of DKD and the implementation challenges.