A patient with type 2 diabetes and stage 3b CKD (eGFR 38 ml/min/1.73m²) needs additional glycaemic control. Current therapy is metformin (dose-reduced). Which agent has demonstrated slowing of CKD progression via intraglomerular pressure reduction in addition to glycaemic control?
- A Glipizide
- B Pioglitazone
- C Finerenone (non-steroidal MRA)
- D Dapagliflozin ✓
Explanation
The DAPA-CKD and CREDENCE trials demonstrated that SGLT2 inhibitors, particularly dapagliflozin and canagliflozin, reduce intraglomerular hypertension by increasing tubuloglomerular feedback (reducing proximal Na+ reabsorption, thus increasing NaCl delivery to macula densa), resulting in afferent arteriolar constriction. This lowers GFR transiently but protects against long-term progression. Glipizide is safe in CKD but has no renoprotective mechanism. Pioglitazone causes fluid retention. Finerenone (FIDELIO-DKD) reduces albuminuria and has renoprotective effects but primarily via anti-fibrotic pathways, not intraglomerular pressure; it also is not primarily used for glycaemic control.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.