Defining the roles of SGLT2 inhibitors and GLP-1 receptor agonists in the management of chronic kidney disease in adults with type 2 diabetes with or without overweight/obesity : an international Delphi consensus

Abstract

Introduction

The optimal positioning and sequencing of sodium-glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in adults with chronic kidney disease (CKD) with type 2 diabetes (T2D) and overweight/obesity is unclear. This Delphi panel aimed to establish expert consensus on the foundational versus adjunctive role of SGLT2is and GLP-1 RAs in this adult population. Methods

A total of 114 participants across 10 countries participated in a two-round Delphi panel (9.7% drop-off rate between rounds). Statement development was guided by a systematic literature review and 12 global experts. Consensus was pre-defined as ≥ 75% agreement/disagreement. The Delphi panel took place between 29 August and 20 October 2025. Results

Totals of 13/30 (43%) and 7/17 (41%) statements achieved consensus in Rounds 1 and 2, respectively. Panellists agreed that SGLT2is should be foundational therapy in adults with CKD and T2D, independent of body mass index (BMI). Consensus was also achieved that GLP-1 RAs should be considered as an add-on for those with BMI ≥ 35 kg/m2 and cardiometabolic complications and comorbidities [e.g. residual glycated haemoglobin A1c (HbA1c) elevation, atherosclerotic cardiovascular disease]. Combination therapy was considered appropriate for adults with persistent kidney disease progression, high cardiovascular risk or suboptimal metabolic control. Conclusion

While treatment of adults with CKD and T2D should be holistic, SGLT2is should be prioritised as foundational therapy, independent of BMI, to reduce cardiorenal risk. Combination therapy with GLP-1 RAs was preferred for those with ongoing CKD progression and/or high cardiometabolic risk. Further clarity is required around the optimal timing of combination and sequential add-on therapy initiation.