CKD Care Has Entered a New Era

Chronic kidney disease (CKD) care has entered a new era, but what does this mean for nephrologists managing patients today?

After decades with few disease-modifying options beyond blood pressure control and renin-angiotensin system blockade, clinicians now have multiple therapies targeting different pathways involved in kidney disease progression. The challenge in 2026 is no longer simply whether effective treatments exist, but how best to identify patients who need them and implement them in practice.

“I think a lot of nephrologists have been sort of swayed to sleep by 20 to 25 years of really no groundbreaking developments in how we manage chronic kidney disease,” said Marc Richards, MD. “We've gone from that to now potentially 3 new classes of agents on the market, and potentially more, that can delay progression of kidney disease in our patients and prevent progression to end-stage kidney disease.”

Historically, CKD care focused largely on controlling blood pressure, managing diabetes, and slowing kidney damage with renin-angiotensin system (RAS) blockade. However, the treatment landscape has expanded with therapies targeting multiple pathways involved in kidney disease progression, proteinuria, cardiovascular risk, and metabolic dysfunction.

“The modern management of CKD relies on the integration of foundational and newer nephroprotective therapies,” Richards said.

From Supportive Care to Disease-Modifying Therapy

The expanding CKD treatment landscape reflects a shift toward evidence-based therapies that target specific mechanisms involved in disease progression.

“Now our data is exploding,” Richards said. “We have evidence with ACE inhibitors and ARBs for proteinuric kidney disease states. We have SGLT2 inhibitors becoming a standard of care. We now have the nonsteroidal MRAs that are on the market, both in diabetic and—now we're learning—non-diabetic kidney disease, that could benefit our patients. Data is emerging with GLP-1 agonists.”

RAS inhibitors, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), remain foundational therapies for patients with CKD, particularly those with proteinuric disease.

“RAS inhibitors such as ACE inhibitors or angiotensin receptor blockers have a long and safe history of being the first-line therapy for treatment of diabetes and kidney disease, and even high blood pressure,” Richards said. “That remains unchanged.”

Over the past decade, sodium-glucose cotransporter-2 (SGLT2) inhibitors have become another cornerstone of CKD management, with evidence supporting kidney and cardiovascular benefits across broad patient populations.

“Over the last decade, we've now added SGLT2 inhibitors that have the added benefit of preventing heart failure and cardiovascular disease, and even progression of kidney disease,” Richards said. “They now form the cornerstone of treating all chronic kidney disease.”

Nonsteroidal mineralocorticoid receptor antagonists (MRAs), including finerenone, have further expanded treatment options, particularly among patients with proteinuric kidney disease.

“The nonsteroidal mineralocorticoid receptor antagonists are added on, especially in people who have proteinuric kidney disease,” Richards said.

The Cardio-Kidney-Metabolic Connection Expands CKD Care

Another major shift in CKD management has been the recognition that kidney disease cannot be treated independently from cardiovascular and metabolic health.

Glucagon-like peptide-1 (GLP-1) receptor agonists, once primarily viewed as glucose-lowering therapies, are increasingly being incorporated into CKD care because of their cardiovascular and metabolic benefits.

“Over the last few years, the biggest shift is that GLP-1 agonists have gone from being viewed as just glucose-lowering drugs to drugs that now treat the broader cardio, kidney, metabolic syndrome,” said Pranav Garimella, MD.

“That’s really critical because we’ve come to realize that we can’t treat these organs in silos anymore,” he continued. “The kidneys, the heart, and the metabolic system are intricately tied together.”

Garimella said GLP-1 receptor agonists should now be considered part of the broader CKD treatment toolkit.

“GLP-1s no longer belong just in the treatment of diabetes, but they are integral to preventing heart failure and kidney disease progression,” he said.

However, he emphasized that GLP-1 receptor agonists should be viewed as complementary to existing kidney-protective therapies rather than replacements for foundational treatments.

For example, a patient with CKD, hypertension, diabetes, and proteinuria may benefit from RAS blockade followed by an SGLT2 inhibitor and potentially a nonsteroidal MRA. In contrast, a patient with CKD, obesity, sleep apnea, and increased cardiovascular risk may derive additional benefit from GLP-1 receptor agonist therapy.

“The GLP-1s are seen now as complementary,” Garimella said.

Emerging Targets: The Role of Aldosterone in CKD

Beyond currently established therapies, researchers continue to investigate additional pathways involved in CKD progression, including aldosterone signaling.

Richards said aldosterone has become an increasingly important therapeutic target because of its effects on cardiovascular and kidney health.

“Now we have a focus on targeting aldosterone as a way of trying to help limit stress on the kidney or limit stress on the heart,” Richards said. “With older drugs like spironolactone and eplerenone, newer medicines like finerenone, and even looking into novel agents like aldosterone synthase inhibitors to even prevent aldosterone from being released in the first place.”

Aldosterone contributes to processes including hypertension, electrolyte abnormalities, and organ stress over time, making it an important pathway of interest for future CKD therapies.

Beyond eGFR: Moving Toward Personalized CKD Management

While the expansion of treatment options has changed CKD care, experts emphasized that effective management still depends on understanding the individual patient and their underlying disease drivers.

Matthew Breeggemann, MD, said evaluating CKD requires looking beyond a single kidney function measurement.

“I think for me it’s really helpful to get a really detailed history when you first meet them, and this would include the patient and the patient’s family, and just trying to fit those pieces of the puzzle together,” Breeggemann said.

A patient with diabetes may have straightforward diabetic kidney disease, he explained, while another patient may have diabetes along with hypertension, kidney stones, or other contributors that require a different management approach.

When assessing CKD severity, Breeggemann said clinicians should focus on trends over time rather than isolated values.

“I really want to see the trend,” he said.

He explained that one patient may have an eGFR of 50 mL/min/1.73 m² that remains stable for years, while another patient with the same baseline value may experience a rapid decline over a short period of time.

Beyond laboratory values, Breeggemann highlighted the growing role of precision approaches, including genetic testing and kidney biopsy.

“Our center also does perform a substantial amount of genetic testing for kidney disorders, and these findings have definitely led to a change in how we approach and manage some patients with CKD,” he said.

He also emphasized the importance of incorporating patient preferences into treatment decisions.

“We want to ensure that patients understand why we recommend what we recommend, and importantly, lastly, take into account the patient’s priorities for their own care to really make sure we’re working with them and honoring their treatment preferences,” Breeggemann said.

Recognizing AKI as a Driver of Long-Term Kidney Health

Another shift in kidney care has been the recognition that acute kidney injury (AKI) may have long-term consequences for kidney health.

Breeggemann said AKI should not be viewed simply as a temporary event that resolves once creatinine improves.

“An episode of acute kidney injury should not really be viewed as a simple transient condition, even when perhaps labs may improve and then thus suggest so,” he said.

AKI episodes can contribute to structural changes in the kidney, inflammation, cellular injury, and vascular damage, potentially increasing the risk of future CKD development or progression.

“It would be a mistake to just say, okay, great, nothing, no additional evaluation or monitoring is needed,” Breeggemann said.

He added that many patients who experience AKI may not receive consistent follow-up after discharge, despite their increased risk.

The Remaining Challenge: Translating Evidence Into Practice

Despite major advances in CKD treatment, experts said a significant challenge remains: ensuring that evidence-based therapies reach the patients who could benefit.

Breeggemann noted that implementation of new therapies often takes years.

“It takes approximately 17 years following a new medical intervention or therapy to be routinely used in clinical practice,” he said.

Barriers include delayed diagnosis, delayed referral to nephrology, insurance challenges, clinician familiarity, and coordination between specialties.

Garimella also highlighted clinician familiarity as an ongoing challenge as GLP-1 receptor agonists expand beyond diabetes care.

“Historically we viewed these medications as being exclusively diabetic medications,” he said. “However, now we know that these medications can prevent kidney disease progression; they can prevent heart disease progression.”

Looking ahead, Richards said continued research will be essential to further improve CKD care.

“Potentially the next great treatment is out there, but we just need to get patients into clinical trials to see if we can establish new standards of care to optimize management of our patients,” he said.

Editor’s Note: Richards reports no relevant disclosures; Garimella has relevant disclosures with Otsuka and the PKD Foundation.

References

1. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group.
   Kidney Disease: Improving Global Outcomes (KDIGO) 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314. doi:10.1016/j.kint.2023.10.018

2. Heerspink HJL, Stefánsson BV, Correa-Rotter R, et al.
   Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-1446. doi:10.1056/NEJMoa2024816

3. The EMPA-KIDNEY Collaborative Group.
   Empagliflozin in patients with chronic kidney disease. N Engl J Med. 2023;388(2):117-127. doi:10.1056/NEJMoa2204233

4. Bakris GL, Agarwal R, Anker SD, et al.
   Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. N Engl J Med. 2020;383(23):2219-2229. doi:10.1056/NEJMoa2025845

5. Perkovic V, Tuttle KR, Rossing P, et al.
   Effects of semaglutide on chronic kidney disease in patients with type 2 diabetes. N Engl J Med. 2024;391:109-121. doi:10.1056/NEJMoa2403347

6. Agarwal R, Green JB, Heerspink HJL, et al.
   Finerenone with empagliflozin in chronic kidney disease and type 2 diabetes. N Engl J Med. 2025;393:533-543. doi:10.1056/NEJMoa2410659