{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T23:40:00Z","timestamp":1792194000584,"version":"4.4.0"},"reference-count":138,"publisher":"American Diabetes Association","issue":"9","license":[{"start":{"date-parts":[[2023,8,25]],"date-time":"2023-08-25T00:00:00Z","timestamp":1692921600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/www.diabetesjournals.org\/journals\/pages\/license"}],"content-domain":{"domain":["diabetesjournals.org"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2023,9,1]]},"abstract":"<jats:p>Management of diabetic kidney disease (DKD) has evolved in parallel with our growing understanding of the multiple interrelated pathophysiological mechanisms that involve hemodynamic, metabolic, and inflammatory pathways. These pathways and others play a vital role in the initiation and progression of DKD. Since its initial discovery, the blockade of the renin-angiotensin system has remained a cornerstone of DKD management, leaving a large component of residual risk to be dealt with. The advent of sodium\u2013glucose cotransporter 2 inhibitors followed by nonsteroidal mineralocorticoid receptor antagonists and, to some extent, glucagon-like peptide 1 receptor agonists (GLP-1 RAs) has ushered in a resounding paradigm shift that supports a pillared approach in maximizing treatment to reduce outcomes. This pillared approach is like that derived from the approach to heart failure treatment. The approach mandates that all agents that have been shown in clinical trials to reduce cardiovascular outcomes and\/or mortality to a greater extent than a single drug class alone should be used in combination. In this way, each drug class focuses on a specific aspect of the disease's pathophysiology. Thus, in heart failure, \u03b2-blockers, sacubitril\/valsartan, a mineralocorticoid receptor antagonist, and a diuretic are used together. In this article, we review the evolution of the pillar concept of therapy as it applies to DKD and discuss how it should be used based on the outcome evidence. We also discuss the exciting possibility that GLP-1 RAs may be an additional pillar in the quest to further slow kidney disease progression in diabetes.<\/jats:p>","DOI":"10.2337\/dci23-0030","type":"journal-article","created":{"date-parts":[[2023,8,25]],"date-time":"2023-08-25T15:04:52Z","timestamp":1692975892000},"page":"1574-1586","update-policy":"https:\/\/doi.org\/10.2337\/ada-journal-policies","source":"Crossref","is-referenced-by-count":289,"title":["Diabetic Nephropathy: Update on Pillars of Therapy Slowing Progression"],"prefix":"10.2337","volume":"46","author":[{"given":"Sandra C.","family":"Naaman","sequence":"first","affiliation":[{"name":"Section of Endocrinology, Diabetes, and Metabolism, Department of Medicine, and American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1183-1267","authenticated-orcid":false,"given":"George L.","family":"Bakris","sequence":"additional","affiliation":[{"name":"Section of Endocrinology, Diabetes, and Metabolism, Department of Medicine, and American Heart Association Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, IL"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1167","published-online":{"date-parts":[[2023,8,25]]},"reference":[{"key":"2023082519043352200_B1","doi-asserted-by":"crossref","first-page":"2165","DOI":"10.1046\/j.1523-1755.2002.00356.x","article-title":"Albuminuria and renal insufficiency prevalence guides population screening: results from the NHANES III","volume":"61","author":"Garg","year":"2002","journal-title":"Kidney Int"},{"key":"2023082519043352200_B2","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1007\/s11892-018-0980-x","article-title":"The landscape of diabetic kidney disease in the United States","volume":"18","author":"Duru","year":"2018","journal-title":"Curr Diab Rep"},{"key":"2023082519043352200_B3","doi-asserted-by":"crossref","first-page":"89","DOI":"10.2337\/dc20-1913","article-title":"Worldwide epidemiology of diabetes-related end-stage renal disease, 2000-2015","volume":"44","author":"Cheng","year":"2021","journal-title":"Diabetes Care"},{"key":"2023082519043352200_B4","unstructured":"National Institute of Diabetes and Digestive and Kidney Diseases\n          . 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