Chronic Kidney Disease Stage G4 in a Diabetic Patient Improved by Multi-Disciplinary Treatments Based Upon Literature Search for Therapeutic Evidence

In the EMPA-REG OUTCOME trial, sodium-glucose cotransporter 2 (SGLT2) inhibitor, empagliflozin, reduced incident or worsening nephropathy. In the LEADER trial, a glucagon-like peptide 1 (GLP-1) receptor agonist, liraglutide, resulted in lower rates of the development and progression of diabetic kidney disease than placebo. Therefore, the American Diabetes Association and the European Association for the Study of Diabetes recommend the decision to treat high-risk individuals with a GLP-1 receptor agonist or SGLT2 inhibitor to reduce chronic kidney disease (CKD) progression should be considered. A 72-year-old male obese diabetic patient developed CKD stage G4 despite of use of both SGLT2 inhibitor and GLP-1 receptor agonist. We started using sodium bicarbonate because he showed metabolic acidosis due to uremia. We also started to use spherical carbonaceous adsorbent which adsorbs indole, the precursor of indoxyl sulfate, uremic toxin. We started the treatment with finerenone, a nonsteroidal, selective mineralocorticoid receptor antagonist, which has been recently shown to lower risks of CKD progression. Considering unfavorable effects of hyperuricemia on CKD, to treat his hyperuricemia, we started to use dotinurad, a novel selective urate reabsorption inhibitor, which reduces serum urate levels by selective inhibition of urate transporter 1. The improvement of CKD stage G4 in a diabetic patient was obtained by such multi-disciplinary treatments in addition to SGLT2 inhibitor and GLP-1 receptor agonist.