Rethinking Glycemic Thresholds: Diabetic Kidney Disease in the Absence of Overt Diabetes.

Diabetic kidney disease is traditionally regarded as a complication of chronic hyperglycaemia associated with diabetes. However, the relationship between glycaemic thresholds and the development of diabetic kidney disease is increasingly questioned. We present a case of a 69-year-old woman with progressive renal dysfunction and biopsy findings suggestive of diabetic kidney disease, despite repeatedly normal glycosylated haemoglobin (haemoglobin A1c) and without a clinical diagnosis of diabetes or pre-diabetes. This case highlights the limitations of current haemoglobin A1c thresholds and raises the question of whether diabetic kidney disease can truly develop in the absence of diabetes. Stricter glycaemic criteria may help identify at-risk patients earlier and prevent renal complications. LEARNING POINTS: Diabetic kidney disease can occur without overt diabetes or pre-diabetes, challenging current diagnostic methods.Reliance on haemoglobin A1c alone may miss at-risk individuals, and stricter glycaemic thresholds may be warranted.The diagnosis of diabetic kidney disease in normoglycemic patients challenges disease definitions and pathogenesis.