This review argues for earlier combined risk-based therapy for in people with instead of slow stepwise escalation.
Evidence
The article is a narrative review for primary care practitioners, discussing guideline-directed options including RAS inhibitors, SGLT2 inhibitors, finerenone, and GLP-1 receptor agonists, with CONFIDENCE trial data noted for simultaneous finerenone and empagliflozin initiation on background RASi.
Caveat
Because it is a narrative review, the proposed is a practical synthesis rather than a new head-to-head outcomes trial of the full strategy.
Simplified
continues to be a significant burden for people living with , despite the available guideline-directed treatment options. Traditionally, a stepwise approach has been implemented for the management of chronic kidney disease and type 2 diabetes, which involves the linear sequential initiation of one therapy after the other on the basis of an individual's treatment outcomes. However, this approach is not beneficial for all individuals, as it can lead to treatment inertia and subsequent disease progression. Therefore, primary care practitioners should consider implementing a more proactive treatment strategy to optimize care. The is an emerging concept with goals of glucose control and blood pressure control as well as comprising simultaneous or rapid sequential initiation of multiple therapies, such as renin-angiotensin system inhibitors (RASi), sodium-glucose cotransporter 2 inhibitors, a nonsteroidal mineralocorticoid receptor antagonist (finerenone), and glucagon-like peptide-1 receptor agonists, which target the different hemodynamic, metabolic, and fibrotic/inflammatory pathways involved in chronic kidney disease and type 2 diabetes. This approach enables earlier chronic kidney disease risk reduction, and the recently published CONFIDENCE trial reported tolerability and efficacy of simultaneous initiation of two of these therapies (finerenone and empagliflozin) in those already receiving RASi. This review article provides primary care practitioners with practical considerations, discussing current guideline-directed treatment options for chronic kidney disease in people with type 2 diabetes in the context of a historical stepwise approach versus the new patient-centric pillar risk-based approach.
Key numbers
50%
Prevalence in
Proportion of people with affected by .
52%
Reduction in with Combination Therapy
Percentage reduction in urine albumin-to-creatinine ratio after 180 days.
3.2 years
Estimated Major Adverse Cardiovascular Event-Free Survival Increase
Estimated increase in event-free survival for a 50-year-old starting combination therapy.
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