Background: Elevated intracranial pressure (ICP) is a potentially life-threatening condition requiring prompt intervention. While both mannitol and hypertonic saline (HTS) are commonly used hyperosmotic agents for treating elevated ICP, there is insufficient evidence comparing their renal safety profiles and overall effectiveness. This study protocol outlines a pragmatic randomized trial to compare protocol- based 11.7% HTS with 20% mannitol in patients with elevated ICP, focusing particularly on renal outcomes and treatment efficacy. Methods: This single-center, pragmatic randomized trial will enroll 116 intensive care unit patients with elevated ICP. Participants will be randomly assigned to receive either 11.7% HTS or 20% mannitol following a schedule-based randomization approach, with HTS administration during odd-numbered months and mannitol during even-numbered months. The study will regularly monitor serum electrolytes, osmolarity, and renal function, with brain CT evaluations conducted on days 3 and 7. Comprehensive clinical assessments, including neurological evaluations and laboratory tests, will be performed at specified intervals throughout the study period. Measured Outcomes: Primary outcomes include the incidence of acute kidney injury within 7 days according to KDIGO guidelines, requirement for mechanical ventilation, development of pulmonary edema, and significant fluid retention. Secondary outcomes encompass ICU and hospital length of stay, 30- and 90-day mortality rates, and neurological outcomes assessed by Glasgow Coma Scale scores at days 7 and 30. The study hypothesizes that protocol-based HTS administration will demonstrate a lower incidence of acute kidney injury and related complications while maintaining comparable efficacy in managing elevated ICP. Conclusion: This study aims to provide definitive evidence regarding the relative efficacy and safety profiles of HTS compared to mannitol in managing elevated ICP. The findings will help establish clearer clinical guidelines for selecting appropriate hyperosmotic agents, potentially improving patient care outcomes and reducing treatment-related complications. This research will address a significant gap in current clinical knowledge and practice by focusing on treatment efficacy and renal safety considerations in patients with elevated ICP.

Diabetic kidney disease (DKD) is a leading cause of chronic kidney disease (CKD). Recent advancements highlight the role of finerenone, a non-steroidal mineralocorticoid receptor antagonist (nsMRA), in DKD management. Studies like FIDELIO-DKD, FIGARO- DKD, and FIDELITY have demonstrated finerenone’s efficacy in reducing CKD progression and cardiovascular risks in DKD patients. Trials reveal higher incidence of hyperkalemia in finerenone groups compared to controls. Asian populations are noted to have a higher risk, emphasizing the need for close monitoring. To manage hyperkalemia, evidence-based protocols suggested starting finerenone with potassium level below 4.8 mEq/L, discontinuing if potassium level exceed 5.5 mEq/L. Strategies include dietary potassium restriction, potassium binders, and frequent monitoring. While these managements help mitigate risks, real-word challenges call for further evidence to refine practical guidelines. Finerenone emerges as a promising therapy for DKD but requires careful management to prevent hyperkalemia, ensuring optimal patient outcomes.

Diabetic kidney disease (DKD) is a prevalent and complex disease among patients with diabetes in Korea, requiring comprehensive treatment strategies. Traditional management strategies targeting blood pressure, blood sugar, lipid, and lifestyles are foundational approaches of DKD treatment, each of them still holding importance in current paradigms. The four pillars, renin-angiotensin system (RAS) inhibitors, sodium-glucose cotransporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and non-steroidal mineralocorticoid receptor antagonists (nsMRA) can enhance DKD treatment. Expanding beyond these pillars with future-oriented pillars including precision medicine, digital health, gut health, anti-inflammatory/ fibrotic agents, psychosocial/behavioral health, and regenerative medicine can further advance DKD treatment strategies, offering a more cohesive framework which shifts a disease-centered approach to a patient-centered approach.