<![CDATA[Background: One of the main causes of end-stage renal disease in the globe is diabetic kidney disease (DKD). Estimated glomerular filtration rate (eGFR) and albuminuria are examples of conventional biomarkers that frequently miss early microstructural alterations prior to a major functional loss. Using metrics like fractional anisotropy (FA) and apparent diffusion coefficient (ADC), diffusion tensor imaging (DTI) provides a non-invasive method of measuring renal tissue integrity. Objective: The objective of this systematic review is to identify patterns of DTI parameter alterations, assess their link with clinical indicators, and compile information about the relevance of DTI in detecting renal microstructural changes in DKD. Methods: A systematic literature search was conducted in PubMed, Scopus, Google Scholar, ScienceDrect for original research articles reporting renal DTI parameters in DKD patients published between 2017 and 2025. The review followed PRISMA guidelines. Data were extracted using a standardized form and synthesized narratively. Methodological quality was assessed using QUADAS-2 for diagnostic accuracy studies, Newcastle-Ottawa Scale for cohort studies, and JBI Critical Appraisal Checklist for clinical trials. Results: The inclusion criteria were met by ten original studies. Quality assessment revealed four studies with low risk of bias and six with moderate risk, primarily due to lack of histopathological correlation. FA levels were repeatedly found to be considerably lower in DKD patients compared to healthy participants in observational studies. The most consistent differences between DKD and controls were found in medullary FA. FA had an inverse relationship with albuminuria and serum creatinine, and a correlation with eGFR (r values ranging from 0.38 to 0.69). ADC results were more inconsistent, with some studies finding no discernible differences and others reporting lower ADC in diabetics. A significant rise in FA after intervention (from 242.57±63.97 to 305.61±152.32, p=0.042) was reported in one clinical trial assessing autologous dendritic cell treatment, indicating DTI's potential for tracking therapeutic response. Conclusion: As a non-invasive biomarker for identifying renal microstructural alterations in DKD, DTI, in particular medullary FA, shows potential. FA's diagnostic value is supported by its association with renal function measures and its persistent decrease in DKD patients. To determine DTI's place in clinical practice, more studies using standardized procedures and long-term designs are required.]]>
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