Medical treatment for diabetic acute kidney disease from 2012 to 2024: advances, prescription trends, and future directions

Diabetic acute kidney disease (AKD) represents a pivotal transitional phase between acute kidney injury (AKI) and chronic kidney disease (CKD), carrying a high risk of progression to end-stage kidney disease. Effective medical management is crucial during this phase. Renin-angiotensin-aldosterone system inhibitors remain the foundation of therapy, and newer agents have expanded the armamentarium. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists have been shown to confer significant nephroprotective and cardioprotective effects, including decreased risks of AKD progression, heart failure, and mortality. Finerenone, a novel nonsteroidal mineralocorticoid receptor antagonist, has also been shown to reduce kidney disease progression and cardiovascular events in patients with established diabetic CKD, although its role in AKD remains uncertain. However, real-world data indicate the suboptimal utilization of these therapies, highlighting barriers related to clinical inertia, safety concerns after AKI, and socioeconomic disparities. Future strategies should emphasize the timely initiation and combination of treatments to maximize renoprotection, while exploring emerging agents such as endothelin receptor antagonists and aldosterone synthase inhibitors. Integrating evidence-based therapies, improving adherence to guideline-directed care, and leveraging real-world data to inform clinical practice are necessary to optimize kidney and cardiovascular outcomes in patients with diabetic AKD.