Chronic kidney disease in diabetes and hypertension: nephrological management from internal medicine in the growing chronic disease epidemic

Abstract

Introduction: Chronic kidney disease (CKD) affects over 800 million people worldwide, with diabetes mellitus and hypertension as its main drivers (Kushner & Mende, 2026). In recent decades, the approach has evolved from isolated renin-angiotensin system blockade to a multi-target strategy including SGLT2 inhibitors, finerenone, and GLP-1 receptor agonists (Deedwania, 2026; El Din et al., 2022). Objective: To synthesize evidence on the nephrological approach to CKD associated with diabetes and hypertension from an internal medicine perspective, through an exploratory systematic review with PICO questions. Methods: Exploratory systematic review following PRISMA 2020 (Page et al., 2021). Three PICO questions were formulated. Search in PubMed/MEDLINE, Scopus, and Cochrane Library (January 2000 to October 2026). Systematic reviews, meta-analyses, and randomized clinical trials on nephroprotective interventions in diabetic and hypertensive CKD were included. Results: Seventy-two records were identified; after screening, 9 studies were included. SGLT2 inhibitors reduce CKD progression and cardiovascular events, with benefits independent of diabetes status (El Din et al., 2022; Deedwania, 2026). Finerenone reduces composite kidney and cardiovascular outcomes in diabetic CKD, with hyperkalemia as the main adverse effect (Sato & Nishimoto, 2025; Sarafidis et al., 2023). The FIDELITY analysis confirmed that benefit is greater when initiated in early CKD stages (Sarafidis et al., 2023; Singh et al., 2026). Semaglutide reduced the risk of major kidney events in the FLOW trial (Rossing et al., 2024). The combination of the four strategies (RAS blockade, SGLT2i, finerenone, and GLP-1 RA) is associated with substantial projected gains in kidney and cardiovascular survival (Kushner & Mende, 2026; Shenoy et al., 2021). Conclusions: The modern approach to CKD associated with diabetes and hypertension requires a multi-target, individualized strategy. Internal medicine plays a central role in coordinating these therapies, monitoring kidney function and serum potassium, and implementing the "four pillars" of nephroprotective treatment. Prospective studies evaluating the implementation of this strategy in real-world clinical practice are required (Page et al., 2021).