GLP-1 receptor agonists are now considered a fourth therapeutic pillar for CKD in T2D alongside RAAS inhibitors, SGLT2i, and finerenone, with expert guidance on sequencing and combining these treatments.
Fourth pillarGLP-1 drugs join RAAS inhibitors, SGLT2i, and finerenone as the fourth established kidney-protective drug class in T2D
What the researchers found
GLP-1 RAs are now the fourth therapeutic pillar for CKD in T2D, with expert guidance on integrating them with RAAS inhibitors, SGLT2i, and finerenone based on individual patient factors.
Why it matters
Diabetic kidney disease leads to dialysis and death. Having four drug classes for kidney protection — and knowing how to combine them — could dramatically improve outcomes.
How the study worked
Expert opinion synthesizing landmark trial evidence (FLOW, CREDENCE, FIDELIO-DKD, etc.) to provide guidance on four-pillar CKD management in T2D.
What this study cannot tell us
Expert opinion. Optimal combinations and sequencing not established by RCTs. Resource and cost implications of four-drug regimens.
How to read the evidence
Expert opinion based on landmark trial evidence. Practical guidance but combination strategies need prospective validation.
When this study was published
Published in 2025, incorporating FLOW trial results.
The bigger picture
The evolution from one to four kidney-protective drug classes represents a transformation in diabetic nephrology, requiring new clinical algorithms.
Questions still open
- What is the optimal order for starting the four pillars?
- Can all four be used simultaneously safely?
- Which patients benefit most from adding GLP-1 RA to three-drug therapy?
Common questions
What are the four pillars for diabetic kidney disease?
Do I need all four drugs?
Read the original research
Expert perspectives on incorporating glucagon-like peptide-1 receptor agonist in diabetes and chronic kidney disease: challenges and opportunities.
European journal of preventive cardiology, 33(1), 8-18
Citation
Halimi, Jean-Michel; Fauchier, Laurent; Karras, Alexandre; Amouyal, Chloé; Eladari, Dominique; Rossignol, Patrick; Choukroun, Gabriel; Zaoui, Philippe; Girerd, Nicolas; Hadjadj, Samy. (2026). Expert perspectives on incorporating glucagon-like peptide-1 receptor agonist in diabetes and chronic kidney disease: challenges and opportunities.. European journal of preventive cardiology, 33(1), 8-18. https://doi.org/10.1093/eurjpc/zwaf426