Chronic Kidney Disease (CKD) affects a significant 9.1% of the global population, posing substantial health risks such as cardiovascular disease (CVD), kidney failure, and increased mortality. Medical experts emphasize the importance of using validated prognostic tools to improve CKD management. These tools, including the Kidney Failure Risk Equation (KFRE), risk for 40% GFR decline, the PREVENT tool for predicting CVD events, and the advanced CKD risk tool, offer critical insights into disease progression and patient outcomes. Despite advancements in therapy, a gap remains in understanding optimal application and timing, necessitating a risk-directed approach to treatment.
The Kidney Disease Improving Global Outcomes (KDIGO) international guidelines have introduced the CKD heatmap, which stages eGFR and albuminuria to assist in evaluating disease severity. However, a concerning trend emerges from the US Renal Data System data: over one-fifth of Medicare beneficiaries with diabetes and stage 3 CKD did not receive ACE inhibitors or ARBs in 2022. Furthermore, the use of SGLT2 inhibitors remains below 15%, even among those with diabetes, CKD, or heart failure.
“Unfortunately, awareness of CKD and its related risks is low, both among patients and providers,”
- Morgan Grams, MD, of New York University Grossman School of Medicine, New York City
The prognostic tools mentioned earlier play distinct roles in CKD management. The KFRE estimates the risk of kidney failure over two and five years for patients with an eGFR below 60 ml/min/1.73 m². Conversely, the 40% decline in eGFR equation predicts short-term kidney function decline where KFRE may fall short. The advanced CKD risk tool employs a nine-variable model to anticipate risks for kidney failure, CVD, and death within two to four years for patients with an eGFR below 30 ml/min/1.73 m².
The PREVENT tool enhances the previous pooled cohort equation by delivering race-free risk predictions, subtypes of CVD risks, and both 10-year and 30-year risk estimates.
“Leveraging prognostic estimates to guide therapy could help clinicians prescribe CKD-related therapies to those most likely to benefit from their use,”
- Authors of a review, published in Nature Reviews Nephrology
Despite these advancements, a meta-analysis reveals that only 35.1% of individuals with diabetes undergo urinary albumin-to-creatinine ratio screening. This rate drops to 4.1% among those with hypertension. Such findings underscore the need for improved awareness and proactive screening practices.
“Risk-based CKD management thus aligns patient risk and care, allowing the prioritization of absolute benefit in determining therapeutic selection and timing.”
- Authors of a review, published in Nature Reviews Nephrology
From 2012 to 2022, prescribing GLP-1 RAs increased from 1.9% to 12.6% among stage 3 CKD beneficiaries. Additionally, SGLT2 inhibitor prescriptions rose in recent years for this group. Yet, these medications remain underutilized despite their proven efficacy and safety.
“These medications remain underutilized, even in individuals at high risk,”
- Authors
Guidelines recommend annual albuminuria assessments for individuals with diabetes, CKD, hypertension, or CVD. The KDIGO CKD heatmap provides significant risk discrimination within its categories, offering valuable insights for tailored treatment approaches.
“Important risk discrimination even within the categories of the KDIGO CKD heatmap,”
- Authors
To address high-risk cases effectively, experts advocate for a rapid initiation of comprehensive therapy involving SGLT2 inhibitors, GLP-1 RAs, RAAS inhibition, MRAs, and statins for individuals with diabetes and elevated kidney or cardiovascular risk.
“For an individual with diabetes and high kidney or cardiovascular risk, rapid initiation of the four pillars supporting therapy — SGLT2 inhibitors, GLP1RAs, RAAS inhibition and MRAs, along with statins — could be prioritized,”
- Authors
A framework of shared decision-making that incorporates patient preferences alongside clinician expertise can significantly enhance CKD patient outcomes. This approach ensures that treatment decisions align with patient needs and clinical evidence.
“by leveraging a framework of shared decision-making that incorporates patient preferences and clinician experience, risk-directed management offers the potential for profound improvements in the health of individuals with CKD,”
- Authors
Such a proactive strategy could lead to timely interventions while avoiding barriers like long wait times for nephrology consultations and high hospitalization risks.
“A similar rapid sequence approach in CKD might provide similar benefits while avoiding some of the barriers to initiating and intensifying guideline-recommended medical therapy: Long wait times for nephrology clinics and the high risk of intervening hospitalizations and mortality,”
- Authors
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