Diabetic nephropathy 2023-the beginning of a new era

The rapidly increasing number of people with diabetes in recent decades shows how little has been done to prevent this metabolic disease. The incidence and prevalence of diabetic nephropathy is also increasing again after a period of stagnation. Glomerular filtration rates that are too low or too high must be regarded as a significant cardiorenal risk. With the introduction of new, highly effective groups of drugs, the previously common practice of switching to insulin for late diabetic damage will gradually be replaced. Angiotensin-converting enzyme (ACE) inhibitors and sartans reduce blood and intraglomerular pressure and, thus, have an antihypertensive and antiproteinuric effect at the same time. The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are now the gold standard for all nephropathies. SGLT2i therapy should be started as early as possible in order to achieve good long-term effects. Good effects can still be achieved with these drugs for cardiac and renal insufficiency, but therapy should no longer be started if the estimated glomerular filtration rate (eGFR) is < 25 ml/min and 1.73 m2 (dapagliflozin) or < 20 ml/min and 1.73 m2 (empagliflozin). On the other hand, it should not yet be discontinued at an eGFR of 20 ml/min and 1.73 m2, as cardiorenal benefits are also detectable in patients with already severely impaired renal function. Mineralocorticoid receptor antagonists such as finerenone also have cardiorenal protective effects. In their joint guideline, the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) recommend glucagon-like peptide-1 (GLP 1) receptor agonists and SGLT2i as first-line therapy for metabolic control in people with type 2 diabetes with a high risk of atherosclerotic complications.