Catheter-Based Renal Nerve Ablation and Centrally Generated Sympathetic Activity in Difficult-to-Control Hypertensive Patients: Prospective Case Series

Diabetic Kidney Disease: Challenges, Advances, and Opportunities

Background

Diabetic kidney disease (DKD) is the most common cause of the end-stage renal disease (ESRD). Regardless of intensive treatments with hyperglycemic control, blood pressure control, and the use of renin-angiotensin system blockades, the prevalence of DKD remains high. Recent studies suggest that the spectrum of DKD has been changed and many progresses have been made to develop new treatments for DKD. Therefore, it is time to perform a systemic review on the new developments in the field of DKD.

Summary

Although the classic clinical presentation of DKD is characterized by a slow progression from microalbuminuria to macroalbuminuria and by a hyperfiltration at the early stage and progressive decline of renal function at the late stage, recent epidemiological studies suggest that DKD patients have a variety of clinical presentations and progression rates to ESRD. Some DKD patients have a decline in renal function without albuminuria but display prominent vascular and interstitial fibrosis on renal histology. DKD patients are more susceptible to acute kidney injury, which might contribute to the interstitial fibrosis. A large portion of type 2 diabetic patients with albuminuria could have overlapping nondiabetic glomerular disease, and therefore, kidney biopsy is required for differential diagnosis for these patients. Only a small portion of DKD patients eventually progress to end-stage renal failure. However, we do not have sensitive and specific biomarkers to identify these high-risk patients. Genetic factors that have a strong association with DKD progression have not been identified yet. A combination of circulating tumor necrosis factor receptor (TNFR)1, TNFR2, and kidney injury molecular 1 provides predictive value for DKD progression. Artificial intelligence could enhance the predictive values for DKD progression by combining the clinical parameters and biological markers. Sodium-glucose co-transporter-2 inhibitors should be added to the new standard care of DKD patients. Several promising new drugs are in clinical trials.

Key Messages

Over last years, our understanding of DKD has been much improved and new treatments to halt the progression of DKD are coming. However, better diagnostic tools, predictive markers, and treatment options are still urgently needed to help us to better manage these patients with this detrimental disease.

Novel therapies for diabetic kidney disease

Over the past 30 years there have been many complementary therapies developed to achieve glycemic control and have an impact on cardiovascular outcomes, as well as reduce the risk of microvascular disease. The 2 most notable new entries have been the sodium-glucose cotransporter 2 (SGLT2) inhibitors and the glucagon-like peptide-1 (GLP-1) agonists. Both these classes of agents have demonstrated reductions in cardiovascular event rates as well as reductions in blood pressure and weight. Moreover, while both have demonstrated a benefit in slowing nephropathy progression, the SGLT2 inhibitors appear to have a significantly greater effect compared with the GLP-1 agents. There is an ongoing trial specifically powered for renal disease progression, CREDENCE (Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants With Diabetic Nephropathy). Additionally, there are 2 other classes of agents being tested to slow nephropathy progression, a selective endothelin-1 receptor antagonist, atrasantan, in the SONAR (Study of Diabetic Nephropathy With Atrasentan) trial and a nonsteroidal mineralocorticoid receptor antagonist, finerenone, in the FIDELIO (Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus) trial. These and other studies are discussed.

Response and non-response to renal denervation: who is the ideal candidate?

Catheter-based renal denervation (RDN) leads to a considerable decrease of blood pressure in the vast majority of patients with resistant hypertension. However, only minor or no blood pressure change is achieved in some patients. This non-reponse is defined as a reduction of office systolic blood pressure of less than 10 mmHg following RDN. The rates of non-response vary between 8-37%. Here several causes are discussed such as inappropriate patient selection, an ineffective procedure, the subordinate contribution of sympathetic activation for the maintenance of hypertension, and patient conditions such as non-adherence to drug therapy. Based on current evidence, an ideal candidate for RDN has high baseline blood pressure, which is known to be the best predictor for blood pressure reduction after RDN. In order to ensure treatment success further criteria have to be fulfilled, such as exclusion of secondary hypertension and optimised medical therapy.