Diabetes Mellitus and Chronic Kidney Disease: The Future Is Being Surpassed

Diabetes mellitus (DM) continuous to be a global world health problem. The Athlas of the International DM Federation for 2023 estimated that 589 million adults (20-79 years) are living with DM and this number could increase to 853 million by 2050. The mortality induced by DM was estimated as up to 3,4 million deaths in 2023. Trends in age-standardized rates of DM-related complications have decreased in the last 15 years; however, a parallel reduction of the incidence of advanced chronic kidney disease (CKD) requiring renal replacement therapy (RRT) has not been observed. Diabetic kidney disease continues to be the first cause of end-stage renal disease worldwide. Until very recently, an integrated approach for the management of the patient with DM and CKD was based on an adequate style of life and nutritional measures associated with a combined treatment of one or various of five classes of drugs: 1) Angiotensin-Converting-Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (AIIRB). 2) Sodium-glucose-transporter 2 (SGLT2) inhibitors. 3) Glucagon-like peptide-1 receptor agonists (GLP-1 RA). 4). An antagonist of type 1 Endothelin receptor with proved effect to reduce albuminuria and proteinuria. 5) The Mineralocorticoid Receptor antagonist (MRA) Finerenone has been recently tested in RCTs as a renoprotective agent. But, indeed, many new drugs of different therapeutic groups, - many of them proved not to DM management but for the treatment of obesity with or without DM, or HF management -, are now in development and may be added to the five classical pillars described before. These new drugs include other non-steroidal mineralocorticoid receptor antagonists, - Balcinrenone-; aldosterone synthase inhibitors, -Baxdrostat and Vicadrostat-, other GLP1-RA, - Tirzepatide, Survodutide, Retatrutide, Cagrilintide-; other endothelin receptor antagonists,- Zibotentan-; and soluble guanylate cyclase activators,-Avenciguat- . Strategies based on actions on gut microbiota or stem cell therapies will be introduced in the future. The new strategies suggest to combine some of these therapies in adequate personalised doses for an integrated management of patients with DM and CKD. All these measures may ideally be applied in an approach that includes different especialists, patients and health providers, in the context of multidisciplinar teams. Perhaps in the next step we should be able to “fold the curve”, to stop the progression to ESRD and the CV damage in the patients with DM, allowing definitively to decrease DM as the first cause of advaced CKD.