Evidence-Based Guidelines for Intravitreal Anti-VEGF Therapy for Diabetic Retinopathy in Chronic Kidney Disease

Intravitreal therapy using anti-vascular endothelial growth factor (anti-VEGF) has transformed the approach to treating diabetic retinopathy (DR), but its application in individuals with diabetes and chronic kidney disease, the majority of whom have diabetic kidney disease, involves a complex evaluation of risks and benefits. Emerging evidence indicates that the systemic absorption of anti-VEGF agents administered intravitreally may lower circulating VEGF levels and negatively impact the renal endothelium, especially in individuals with pre-existing kidney issues. In this article, we showcase an evidence-based framework for the safe administration of anti-VEGF therapy in patients with DR accompanied by chronic kidney disease. We introduce a novel renoretinal syndrome, which we refer to as anti-VEGF-associated nephropathy (AVAN), and outline diagnostic criteria, severity classifications, biopsy indications, and treatment recommendations to guide clinical practice.