Albuminuria may identify patients more likely to gain kidney benefits from GLP-1 and SGLT2 drugs

Clinical takeaway: Assess urinary albumin along with eGFR when selecting therapy for type 2 diabetes. Patients with albuminuria may gain greater kidney protection from GLP-1 receptor agonists or SGLT2 inhibitors, while the findings raise concern about sulfonylureas in patients without albuminuria.

GLP-1 receptor agonists and SGLT2 inhibitors have transformed cardiorenal care, but studies demonstrating kidney benefits have often included patients with existing kidney damage. Whether similar protection extends to patients without albuminuria has remained less clear.

Researchers emulated a clinical trial using health records and insurance claims from 75,455 US adults with type 2 diabetes and moderate cardiovascular risk who added a GLP-1 receptor agonist or SGLT2 inhibitor, sulfonylurea, or DPP-4 inhibitor to metformin between 2014 and 2022. Median follow-up was 32 months.

At baseline, 13,872 patients (18%) had albuminuria. In this subgroup, the estimated five-year risk of kidney function deterioration was 3.2% with a GLP-1 receptor agonist or SGLT2 inhibitor, compared with 5.4% with a DPP-4 inhibitor—a 40% lower relative risk. The estimated risk with a sulfonylurea was 4.6%.

The remaining 61,583 patients did not have albuminuria at baseline. In this larger group, estimated five-year risks were 2.4% with a GLP-1 receptor agonist or SGLT2 inhibitor and 2.1% with a DPP-4 inhibitor, showing no clear kidney advantage for the newer therapies. Sulfonylureas were associated with a 2.8% risk, 31% higher than with DPP-4 inhibitors.

The results support routinely incorporating urinary albumin into treatment planning. However, the analysis was observational and grouped GLP-1 receptor agonists and SGLT2 inhibitors together, so it cannot establish causation or determine the kidney effects of each class separately.

“These findings will allow us to individualize medication choices that maximally benefit the patient in front of us rather than for the hypothetical ‘average person,’” said corresponding author Alexander Turchin, MD, MS. “Patients and their doctors should discuss how to balance these different risks and benefits in their individual circumstances when choosing their type 2 diabetes medications.”

Source: Turchin A, et al. (2026 Sep 16) BMJ. Renal outcomes in people with type 2 diabetes with and without albuminuria treated with SGLT-2 inhibitors and GLP-1 receptor agonists: target trial emulation