Key result
The four-pillar framework of RAS blockade, SGLT2i, nsMRAs, and GLP-1 RAs transforms DKD management.
Why the study?
Recent therapeutic advances have created a paradigm shift beyond glycemic control and RAS blockade toward a four pillars framework for managing diabetic kidney disease.
The management of diabetic kidney disease has shifted to a 'Four Pillars' framework comprising RAS blockade, SGLT2 inhibitors, nsMRAs, and GLP-1 RAs to target holistic pathophysiology.
Clinicians should implement the four pillars in eligible DKD patients now; extends RCT evidence to support combined pathophysiology-targeted therapy.
The global burden of type 2 diabetes mellitus (T2DM) and chronic kidney disease is rapidly on the rise. For nearly two decades, the therapeutic armamentarium for diabetic kidney disease (DKD) limited to rigorous glycemic control and blockade of the renin–angiotensin system (RAS). However, recent advances in understanding the disease have led to a significant shift in the management of DKD. The current “Four Pillars” framework – comprising RAS blockade, sodium glucose cotransporter 2 inhibitors, non-steroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists – represents a transition from treating a single symptom to targeting the holistic pathophysiology of the disease. This review highlights the paradigm shifts in the management of DKD with the advent of the newer drugs. It also discusses the guideline-directed medical therapy of DKD and the implementation challenges.
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Y. J. Anupama (2026) conducted a review in Diabetic kidney disease. Four Pillars framework (RAS blockade, SGLT2 inhibitors, nsMRAs, GLP-1 RAs) was evaluated. The 'Four Pillars' framework of RAS blockade, SGLT2 inhibitors, nsMRAs, and GLP-1 RAs represents a paradigm shift in diabetic kidney disease management, targeting holistic pathophysiology.
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