Advancements in the understanding and treating of diabetic kidney disease

Diabetes is the leading cause of kidney disease in the United States, accounting for almost half of all incident cases of end-stage kidney disease (kidney failure). Diabetes is a condition in which the body is not able to produce or use a hormone called insulin, which converts sugars in food into energy. When the body does not have enough insulin, blood sugar levels increase. Over the course of several years, high blood sugar levels can damage small blood vessels in the body, such as those in the kidneys. Approximately 30% of people with diabetes develop kidney disease. Diabetes also commonly affects the small blood vessels in the eyes and nerves and increases the risk of cardiovascular disease.

Diabetes typically causes damage to the "filtering units" of the kidney, which can lead to protein leaking into the urine. Guidelines recommend that people with diabetes obtain screening for kidney disease every year using a urine test that detects protein and a blood test that measures kidney function.

Prior to the last decade, treatment for diabetic kidney disease centered on kidney disease risk factors, such as blood sugar control and blood pressure management. The only types of medications available specifically for treating diabetic kidney disease were renin-angiotensin-aldosterone system inhibitors. While these medications effectively slow the progression of kidney disease, they do not eliminate the risk of kidney failure completely.

The last 10 years have seen exciting advancements in diabetic kidney disease treatments. Over this time, several new medications have been discovered to significantly reduce the risk of kidney disease progression in people with diabetes, by about 30%. These classes of medications are called SGLT2 inhibitors, GLP1 receptor agonists and non-steroidal mineralocorticoid antagonists. These discoveries have substantially expanded the arsenal of therapies available for treating diabetic kidney disease and may potentially protect millions from developing severe kidney disease. Moreover, these medications also protect against cardiovascular disease, which is a leading cause of morbidity in people with diabetes. A number of other new agents have also demonstrated promise for the treatment of diabetic kidney disease and are currently being studied.

Advancements in research technologies are transforming our understanding of diabetic kidney disease by providing insight into the disease at the molecular level. Research groups such as the Kidney Precision Medicine Project, sponsored by the National Institute of Health, are applying these technologies to kidney biopsy samples from people with diabetic and other types of kidney disease with the goal of better understanding the molecular processes underlying diabetic kidney disease. From this information, new treatments can be developed that can target specific disease pathways. In combination with the growing arsenal of kidney-protective therapies, enhanced molecular understanding of diabetic kidney disease establishes the groundwork for "precision medicine." "Precision medicine" moves beyond the "one-size-fits-all" approach, aiming to identify how mechanisms of disease differ between individuals so that the right treatments reach the right people at the right time.

All in all, the availability of new treatments and exciting new technologies for understanding diabetic kidney disease reflects a promising turning point in diabetes and diabetic kidney disease care.