Novel Therapeutic Strategies for Patients with CKD and Diabetes

ABSTRACT Chronic kidney disease (CKD) remains a major complication of diabetes mellitus and a leading driver of end-stage kidney disease, cardiovascular morbidity, and premature mortality worldwide. Despite significant advances in the management of CKD, substantial residual cardiorenal risk persists in patients with diabetes. The need for additional therapies that target complementary pathophysiological pathways is therefore critical. This review highlights novel and emerging therapeutic strategies with the potential to further reduce the progression of CKD in patients with diabetes. We explore the clinical rationale and growing body of evidence supporting the use of multi-targeting incretin-based therapies which may provide added metabolic and kidney benefits. We also examine the anti-inflammatory, hemodynamic, and antifibrotic effects of aldosterone synthase inhibitors and endothelin receptor antagonists, which target key pathways involved in progressive kidney injury. In addition, we discuss soluble guanylate cyclase agonists, which modulate the nitric oxide signaling pathway to improve kidney perfusion and reduce albuminuria, as well as emerging therapies such as kidney autologous cell therapy and anti-inflammatory agents targeting cytokine and inflammasome pathways. Importantly, we consider patients with type 1 diabetes and the real-world challenges of translating these advances into practice by addressing economic and access-related barriers that continue to shape treatment uptake and equity in care. Together, these agents represent a promising evolution in the treatment of CKD in diabetes, with the potential to complement existing therapies and address key mechanisms of disease progression. Ongoing and future clinical trials will help define their role in reshaping the standard of care.