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. 2023 Feb 28;38(3):532-541.
doi: 10.1093/ndt/gfac283.

Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease

Robert Nee  1   2 , Christina M Yuan  1   2 , Andrew S Narva  3 , Guofen Yan  4 , Keith C Norris  5
Affiliations

Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease

Robert Nee et al. Nephrol Dial Transplant. .

Abstract

For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.

Keywords: cardiovascular disease; chronic kidney disease; diabetes mellitus; glucagon-like peptide-1 receptor agonist; nonsteroidal mineralocorticoid receptor antagonist; sodium-glucose cotransporter-2 inhibitor.

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Figures

Figure 1:
Figure 1:
KDIGO 2020 treatment algorithm for selecting antihyperglycemic drugs for patients with type 2 diabetes and chronic kidney disease. KDIGO, Kidney Disease: Improving Global Outcomes; eGFR, estimated glomerular filtration rate; DPP-4, dipeptidyl peptidase-4; GLP-1, glucagon-like peptide-1; SGLT2, sodium–glucose cotransporter-2; TZD, thiazolidinedione.
Figure 2:
Figure 2:
Barriers and strategies in implementing new cardiorenal therapies for chronic kidney disease. HIT, health information technology; SDOH, social determinants of health.
Figure 3:
Figure 3:
The Chronic Care Model as the guiding principle for the National Kidney Disease Education Program's (NKDEP) comprehensive educational efforts to foster a population health approach to chronic kidney disease (CKD). CME, continuing medical education; GFR, glomerular filtration rate; NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases; PCP, primary care provider; UACR, urine albumin-creatinine ratio.
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