Sequential Kidney-Protective Therapy Achieved CKD Remission in T2DM Patient Based on eGFR Slope Criterion
Background
Diabetes is a leading cause of chronic kidney disease (CKD) and kidney failure, significantly increasing risks of cardiovascular events and premature death in people with diabetes. Management of type 2 diabetes mellitus (T2DM) with CKD has evolved beyond glycemic control to integrated cardiorenal protection. Current guidelines support layered therapy including maximally tolerated renin-angiotensin system inhibition (RASi), sodium-glucose cotransporter 2 inhibition (SGLT2i), glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy, and finerenone (a nonsteroidal mineralocorticoid receptor antagonist) for persistent albuminuria. Recently, CKD remission has been proposed as a therapeutic goal, defined by an eGFR slope > -1 mL/min/1.73 m2 per year or normalization of eGFR and albuminuria, but real-world validation is scarce.
Study Design
This case report details the kidney-function trajectory of a single patient with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). The patient received sequential kidney-protective therapy, which included maximally tolerated renin-angiotensin system inhibition (RASi), sodium-glucose cotransporter 2 inhibition (SGLT2i), glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy, and finerenone. The primary objective was to evaluate if this sequential combination therapy could lead to the achievement of a recently proposed eGFR slope-based criterion for CKD remission, specifically an eGFR slope greater than -1 mL/min/1.73 m2 per year.
Results
The case report demonstrated that sequential, layered therapy with RASi, SGLT2i, GLP-1RA, and finerenone successfully led to the achievement of a proposed eGFR slope-based criterion for clinical remission of CKD. This criterion defines remission as an eGFR slope greater than -1 mL/min/1.73 m2 per year or normalization of eGFR (≥60 mL/min/1.73 m2) and albuminuria. The patient's kidney-function trajectory, under this multi-drug regimen, met the specified eGFR slope target, indicating a significant improvement beyond merely slowing disease progression. This finding contributes to the scarce real-world evidence on kidney-function trajectories under such sequential combination therapies in T2DM patients with CKD. The report highlights the potential for comprehensive, multi-target pharmacological interventions to induce a state of CKD remission. This observation supports the emerging concept of CKD remission as a tangible therapeutic goal. > The single patient in this case report, receiving a combination of RASi, SGLT2i, GLP-1RA, and finerenone, achieved the proposed eGFR slope-based CKD remission criterion.
Key Findings
- Sequential therapy with RASi, SGLT2i, GLP-1RA, and finerenone was used in a T2DM patient with CKD.
- The patient met the proposed eGFR slope-based criterion for CKD remission.
- CKD remission is defined as an eGFR slope > -1 mL/min/1.73 m2 per year.
- This is one of the first real-world reports evaluating kidney trajectories with sequential combination therapy against this new criterion.
Why It Matters
This case report suggests that achieving clinical remission of CKD in T2DM patients may be possible with a sequential, multi-drug approach. For clinicians, it reinforces the value of combining established kidney-protective therapies like RASi, SGLT2i, GLP-1RA, and finerenone to potentially reverse disease trajectory, not just slow it. While a single case, it provides early real-world evidence supporting the novel CKD remission concept and its attainability. This could shift therapeutic goals from merely slowing progression to actively pursuing remission, potentially influencing future treatment protocols and patient expectations. Further validation in larger cohorts is needed, but it offers a glimpse into advanced cardiorenal protection strategies and the potential for more aggressive, yet beneficial, therapeutic layering in T2DM with CKD.
