Adherence to the Kidney Disease: Improving Global Outcomes CKD Guideline in Nephrology Practice Across Countries

Abstract

Introduction The uptake of the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 chronic kidney disease (CKD) Guideline is not fully described in real-world nephrology practice across the world. Methods We used baseline data from the CKD Outcomes and Practice Patterns Study (2013–2017), a 4-country cohort of patients with estimated glomerular filtration rate <60 ml/min per 1.73 m 2 recruited from national samples of nephrology clinics, to describe adherence to measures for monitoring and delaying CKD progression. Data were collected as in clinical practice, except laboratory measures per protocol in France. Results The mean age ranged from 65 years in Brazil to 72 years in Germany. Albuminuria (mostly proteinuria) was measured routinely in 36% to 43% of patients in Brazil, Germany, and the United States. Blood pressure control (≤140/90 mm Hg) ranged from 49% in France to 76% in Brazil; <40% of patients had blood pressure ≤130/80 mm Hg everywhere but Brazil (52%). More than 40% of nephrologists in Brazil reported a systolic blood pressure target ≤130 mm Hg for nondiabetic patients without proteinuria, but only 19% to 24% elsewhere. Prescription of renin-angiotensin aldosterone system inhibitors ranged from 52% in the United States to 81% in Germany. Dietary advice was more frequent for salt than protein intake; dietitian visits were uncommon. In nondiabetic patients, achievement of all 3 targets including blood pressure ≤130/80 mm Hg, renin-angiotensin aldosterone system inhibition, and dietary advice, ranged from 10% in the United States to 32% in Brazil; in treated diabetic patients, this ranged from 6% to 11% after including hemoglobin A1c target. Conclusion Adherence to recommendations to slow CKD progression is low in typical practice settings, and substantial variation among countries for some indicates opportunities for improvement.

AWAREness of Diagnosis and Treatment of Chronic Kidney Disease in Adults With Type 2 Diabetes (AWARE-CKD in T2D)

“…For patients with CKD and T2D, current clinical practice guidelines recommend a comprehensive strategy to reduce risks of kidney disease progression and CV disease, including glycemic monitoring and blood pressure optimization; treatment with angiotensin-converting enzyme inhibitors (ACEis) or angiotensin receptor blockers (ARBs) in patients with hypertension or albuminuria; treatment with lifestyle therapy for all patients; a sodiumglucose cotransporter-2 inhibitor (SGLT2i) and metformin for patients with T2D, CKD and an estimated glomerular filtration rate (eGFR) !30 mL/min per 1.73 m 2 ; and implementation of a selfmanagement educational program (8e11). Despite recent updates to clinical practice guidelines, the overall uptake of these guidelines are likely suboptimal because adherence to Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines in real-world nephrology practice settings was reported to be low (12). Substantial gaps in quality of CKD care in primary care practice have also been reported, with a high occurrence of uncontrolled hypertension, a low rate of kidney function and blood pressure monitoring, declined ACEi/ARB use over time and underused statins (13,14).…”

Can we cure diabetic kidney disease? Present and future perspectives from a nephrologist's point of view

“…Albuminuria was irregularly measured (36%–43% across countries) and dietary advice was uncommon [63]. Notably, in diabetic patients, for most countries, less than 10% of individuals achieved at least four main guideline‐based targets for clinical care, including BP, RAASi, dietary, and HbA1c [63]. This study exemplified the difficulties of implementing evidence‐based recommended practice broadly and reflected challenges in patient and health care providers’ education, the profile of tolerance of, and patient compliance to current treatments.…”

“…Albeit the innovative milieu in DKD yielded therapies with unprecedented effects on both cardiovascular and kidney outcomes, unleashing completely new frameworks to improve clinical management, there are yet many unmet needs in terms of implementation in the real world. In a prospective cohort study of moderate to advanced CKD patients enrolling patients across the globe, the adherence to guideline-based recommendations for CKD was modest, with broad variations across countries [63]. This study included CKD patients from Brazil, Germany, France, and the USA, with mean eGFR between 25 and 31 ml/min.…”

“…This study included CKD patients from Brazil, Germany, France, and the USA, with mean eGFR between 25 and 31 ml/min. RAASi prescription varied from 52% to 81%, while less than half of patients had systolic BP levels lower than 130 mmHg, except those from Brazil (57%) [63]. Albuminuria was irregularly measured (36%–43% across countries) and dietary advice was uncommon [63].…”

“…RAASi prescription varied from 52% to 81%, while less than half of patients had systolic BP levels lower than 130 mmHg, except those from Brazil (57%) [63]. Albuminuria was irregularly measured (36%–43% across countries) and dietary advice was uncommon [63]. Notably, in diabetic patients, for most countries, less than 10% of individuals achieved at least four main guideline‐based targets for clinical care, including BP, RAASi, dietary, and HbA1c [63].…”