Diabetic kidney disease continues to be a leading etiology of kidney failure. For most of the 20th century, we nephrologists have rightfully focused on the kidney itself while relinquishing diabetes management to our endocrinology colleagues. In recent years, however, a flurry of randomized controlled trials has shown that newer diabetes drugs can both manage blood glucose levels and mitigate deleterious kidney effects.
SGLT2i vs GLP-1a vs DPP-4i
CREDENCE and DAPA-CKD, two of the most highly discussed such trials, focused on the renoprotective effects of sodium-glucose transporter 2 inhibitors (SGLT2i). Other studies, such as LEADER, AWARD-7, and CARMELINA , suggest that glucagon-like peptide 1 agonists (GLP-1a) and dipeptidyl peptidase 4 inhibitors (DPP-4i) also protect the kidneys.
These drugs open a new front in the battle against diabetic kidney disease, but which medication class is the best? Researchers from the St Louis Veterans Affairs Medical Center in Missouri have tried to answer this question.
In the absence of a head-to-head comparisons, they followed a framework proposed by epidemiologists to emulate a 3-year randomized controlled trial of nearly 217,000 US veterans with type 2 diabetesPatients with suboptimally controlled diabetes and early kidney disease were divided among four treatment arms: SGLT2i, GLP-1a, DPP-4i, and sulfonylureas. Risk for the composite outcome of a decline > 50% in the estimated glomerular filtration rate, development of end-stage kidney disease, or all-cause mortality was measured for each arm over the study period.
