Abstract: Diabetic kidney disease (DKD) affects approximately 40% of patients with diabetes and remains the leading cause of end-stage renal disease globally, posing a critical public health challenge. While hyperglycemia has long been considered the primary driver, the persistence of residual renal risk despite intensive glycemic control highlights a critical gap in our understanding of the disease’s multifaceted metabolic origins. This review addresses this gap by shifting the focus beyond the “gluco-centric” paradigm to the synergistic lethality of “glucolipotoxicity.” We synthesize evidence showing how insulin resistance acts as a central hub connecting glucotoxicity and lipotoxicity, triggering a self-perpetuating vicious cycle of injury. Specifically, we dissect the molecular crosstalk across key pathogenic nodes, including the TXNIP-mTOR axis suppressing autophagy, DAG-PKC signaling driving insulin resistance, and the activation of the NLRP3 inflammasome. These intersecting pathways converge to accelerate oxidative stress, mitochondrial dysfunction, and fibrosis. We conclude by discussing the clinical implications of this metabolic framework, emphasizing how emerging multi-target therapies, such as SGLT2 inhibitors and GLP-1 receptor agonists, offer a translational pathway from mechanistic insights to precision medicine for preserving renal function. Keywords: diabetic kidney disease, glucolipotoxicity, insulin resistance, lipotoxicity, oxidative stress
Cao et al. (2026) studied this question.