Mind the gap in kidney care: translating what we know into what we do

Cost-of-illness analysis of chronic kidney disease (CKD) management in the Philippines

AIMS

To conduct the first comprehensive cost-of-illness analysis for chronic kidney disease (CKD) management in the Philippines, estimating direct medical, direct non-medical, and indirect costs across all disease stages and renal replacement therapies (RRT).

METHODS

A combined top-down and bottom-up quantitative approach was employed. Cost data were collected through facility surveys, literature reviews, and expert panel input. The analysis included cost estimated for both non-diabetic and diabetic CKD scenarios across all stages and RRT modalities. Direct medical costs, transportation costs, and productivity losses were calculated for each CKD stage and RRT option.

RESULTS

Annual costs for CKD management increased progressively with disease advancement, ranging from PHP 44,610.36 to PHP 116,590.24 for non-diabetic patients and PHP 46,451.88 to PHP 120,948.12 for diabetic patients, excluding complication-related expenses. Significant cost increases were observed between stages G2-G3a and G3b-G4. Analysis of RRT showed comparable annual direct medical costs across modalities (∼PHP 401,000-560,000), with differences primarily observed in annual direct non-medical and indirect costs, which were lower in transplant recipients compared to patients on maintenance dialysis (PHP 37,920-246,480 for dialysis; PHP 3,160 for KT recipients).

LIMITATIONS

The study primarily focused on urban and semi-urban healthcare facilities, potentially limiting generalizability to rural areas. Long-term cost trajectories and quality-of-life measures were not captured due to the cross-sectional nature of the data.

CONCLUSIONS

This analysis provides crucial evidence supporting early detection and intervention strategies in CKD management. It suggests the promotion of peritoneal dialysis as a cost-effective first-line therapy and highlights the long-term economic benefits of kidney transplantation. The findings have significant implications for health policy and clinical practice in the Philippines, offering a foundation for evidence-informed decision-making to improve CKD management sustainability and patient outcomes.

The evolution of nephrology practice in Egypt: legacy, current challenges, and future directions-a narrative review

Egypt, home to over 114 million people, hosts a diverse and expanding nephrology landscape, anchored by leading academic institutions and tertiary care centers that provide services across the full spectrum of kidney disease-from acute kidney injury (AKI) and chronic kidney disease (CKD) to dialysis and transplantation. Some centers have earned international recognition for their scientific contributions and attract referrals from across the region. Notwithstanding the range of services offered, the Egyptian healthcare system-which includes insurance-based, commercial, and governmental models-faces significant obstacles, such as unequal access to care, a lack of adequate data infrastructure, and resource limitations. This narrative review, authored by a multidisciplinary team of Egyptian nephrology experts, provides a comprehensive overview of nephrology care in Egypt, highlighting current strengths, identifying key challenges, and offering future-oriented solutions to advance kidney health nationwide. It aims to serve as a roadmap for policymakers, stakeholders, clinicians, and researchers committed to improving nephrology care delivery in Egypt and shaping a more equitable, enhanced, and sustainable future.

Are your kidneys ok? Detect early to protect kidney health

Early identification of kidney disease can protect kidney health, prevent kidney disease progression and related complications, reduce cardiovascular disease risk and decrease mortality. We must ask "Are your kidneys ok?" using serum creatinine to estimate kidney function and urine albumin to assess for kidney and endothelial damage. Evaluation for causes and risk factors for chronic kidney disease (CKD) includes testing for diabetes and measurement of blood pressure and body mass index. This World Kidney Day we assert that case-finding in high-risk populations, or even population level screening, can decrease the burden of kidney disease globally. Early-stage CKD is asymptomatic, simple to test for and recent paradigm shifting CKD treatments such as sodium glucose co-transporter-2 inhibitors dramatically improve outcomes and favor the cost-benefit analysis for screening or case-finding programs. Despite this, numerous barriers exist, including resource allocation, healthcare funding, healthcare infrastructure and healthcare-professional and population awareness of kidney disease. Coordinated efforts by major kidney non-governmental organizations to prioritize the kidney health agenda for governments and aligning early detection efforts with other current programs will maximize efficiencies.

Guideline-Recommended Disease-Modifying Therapies for Patients with Cardiorenal Disease: A Call-to-Action Narrative Review

Substantial gaps exist between recommendations for guideline-directed medical therapy (GDMT) for chronic kidney disease (CKD) and its use in real-world clinical practice. This includes suboptimal dosing of renin-angiotensin system inhibitors (RASi), low uptake of sodium-glucose co-transporter 2 inhibitors (SGLT2i) for CKD, and low uptake and/or transient use of potassium binders to manage RASi-induced hyperkalemia. Suboptimal RASi therapy deprives patients of the full cardiorenal benefits associated with RASi, and increases the risk of cardiorenal adverse events and mortality. Hyperkalemia can be managed and optimal RASi dosing can be continued by using novel potassium binders, such as sodium zirconium cyclosilicate or patiromer. Similarly, low uptake of SGLT2i might be associated with the concern of an accelerated decline in estimated glomerular filtration rate and, therefore, disease progression when initiating SGLT2i. Numerous clinical trials have demonstrated that adding SGLT2i to RASi therapy can improve clinical outcomes and prolong patient survival in CKD. The recently published Kidney Disease: Improving Global Outcomes (KDIGO) 2024 clinical practice guideline for the evaluation and management of CKD extends the recommendation of SGLT2i to individuals with CKD without diabetes, reinforces the cardiorenal benefits of optimized RASi, recommends the addition of newer drug classes in suitable patients with CKD, and notes the use of novel potassium binders to manage hyperkalemia and enable optimal use of GDMT. In doing so, the guideline targets achievement of the "quadruple aim" of GDMT in CKD, i.e., enabling optimal use of RASi and SGLT2i in most patients, along with nonsteroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists in diabetic kidney disease. This manuscript constitutes a call to action to raise awareness of the growing clinical and economic burdens of CKD and to promote a united approach to the early detection and optimal treatment of CKD through stricter adherence to GDMT.

Eight months of marathon school training reduced blood pressure, systemic vascular resistance and extracellular water volume

The effects of an eight-month marathon school training program on blood pressure (BP) and underlying hemodynamics were examined in 45 participants and 43 controls. Hemodynamics were recorded using whole-body impedance cardiography, radial tonometric pulse wave analysis, and third-finger BP measurements during passive head-up tilt. The mean ages were 40.9 and 42.2 years, and body mass indexes (BMI) 25.1 and 25.8 kg/m2, respectively. Marathon training decreased mean weight (-1.6 kg), fat percentage (-2.7%), and BMI (-0.5 kg/m2) and increased maximal oxygen uptake (+3.2 ml/kg/min) and insulin sensitivity (+0.013 units) (p < 0.03 for all). During head-up tilt, systolic BP and cardiac output decreased, while diastolic BP, heart rate, and systemic vascular resistance (SVR) increased, but training did not affect these posture-induced changes. Initial aortic and third finger systolic/diastolic BP were numerically but not significantly lower in the marathon vs. control group (by 3.4/2.3 and 5.5/4.5 mmHg, respectively, p > 0.075). Final BP values were significantly lower in the marathon group (by 7.2/4.5 and 10.9/10.2 mmHg, respectively, p < 0.01). Marathon training reduced SVR by 167 dyn×s/cm5×m2(p = 0.041), and extracellular water volume by 0.34 L (p = 0.045). To conclude, aerobic exercise training appears to lower BP, a significant cardiovascular risk factor, by reducing SVR and decreasing extracellular water volume.

Group Medical Care Models Transforming Access to Kidney Disease Treatment: An Argentine Experience

As the prevalence of kidney disease rises in Latin America, there is increasing awareness of the importance of early detection and prevention. However, in a region characterized by socioeconomic inequality, variable access to care, and an overwhelmed primary health system, health professionals must find new and innovative ways of delivering care that is cost effective and mindful of patients' needs and social determinants of health. Group medical care (GMC), a model combining group visits and peer support with personalized care, has emerged as an intervention with proven benefits in clinical outcomes, patient satisfaction, and cost effectiveness in the management of chronic illnesses. In this article we present the case of Renalida, a kidney clinic in Argentina that has adopted GMC to improve access, engagement, and standards of care for older patients with chronic kidney disease (CKD). Beyond it being the first documented case of GMC for CKD in Latin America, Renalida brings to light many of the common barriers to effective early CKD care throughout the region and proposes a viable and holistic solution. In addition, we explore future directions, including the application of implementation science to leverage strategies such as GMC to improve both access to and quality of CKD care.

Are Your Kidneys Ok? Detect Early to Protect Kidney Health

Early identification of kidney disease can protect kidney health, prevent kidney disease progression and related complications, reduce cardiovascular disease risk, and decrease mortality. We must ask "Are your kidneys ok?" using serum creatinine to estimate kidney function and urine albumin to assess for kidney and endothelial damage. Evaluation for causes and risk factors for chronic kidney disease (CKD) includes testing for diabetes and measurement of blood pressure and body mass index (BMI). This World Kidney Day, we assert that case-finding in high-risk populations, or even population-level screening, can decrease the burden of kidney disease globally. Early-stage CKD is asymptomatic and simple to test for and recent paradigm-shifting CKD treatments such as sodium glucose co-transporter-2 inhibitors dramatically improve outcomes and favor the cost-benefit analysis for screening or case-finding programs. Despite this, numerous barriers exist, including resource allocation, healthcare funding, healthcare infrastructure, and healthcare-professional and population awareness of kidney disease. Coordinated efforts by major kidney non-governmental organizations to prioritize the kidney health agenda for governments and aligning early detection efforts with other current programs will maximize efficiencies.

Factors associated with awareness of chronic kidney disease, and impact of awareness on renal prognosis

BACKGROUND

Chronic kidney disease (CKD) awareness could help prevent disease progression through modifiable risk factors. However, few patients with CKD are aware of their disease. We aimed to investigate the factors associated with CKD awareness and impact of CKD awareness on renal prognosis.

METHODS

We investigated the proportion of participants with CKD who answered 'aware of CKD' in the questionnaire among those undergoing health check-ups from 2013 to 2022. Participants included working-age employees and their dependents covered by health insurance associations for large and medium-sized companies. The outcome was defined as the change from 'unaware' to 'aware' of CKD; multivariable logistic regression analysis assessed the association of urine tests or nutritional guidance with CKD awareness. A control group was randomly selected from the unaware group and matched for age, sex, estimated glomerular filtration rate (eGFR), urinary protein categories, and follow-up period. Changes in eGFR slopes before and after awareness were compared using linear mixed-effects models.

RESULTS

Of the 13,489 participants, 2.8% were aware of CKD at baseline; of the 1,614 with CKD-related disease codes, only 19.6% were aware. The odds ratios of urine tests or nutritional guidance in relation to awareness occurrence were 1.98 (1.29-3.05) and 3.01 (1.38-6.53), respectively. The difference in the eGFR slope improvement from before to after CKD awareness was + 0.92 mL/min/1.73 m2 per year (0.18-1.67; P = 0.015) in the aware group.

CONCLUSION

Our findings suggest that urine tests and nutritional guidance may promote CKD awareness, which may help slow its progression.

Population Health Management and Guideline-Concordant Care in CKD: A Secondary Analysis of Kidney Coordinated HeAlth Management Partnership

Key Points

Implementation gaps in guideline-concordant care for CKD are associated with poor clinical outcomes. A population health management–based, multidisciplinary approach improved exposure days to sodium-glucose cotransporter-2 inhibitor and glucagon-like peptide-1 receptor agonists compared with usual care. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in albuminuric patients and statin use was not improved, nor was BP control, glycemic control, or albuminuria testing.

Background

Gaps in guideline-concordant care for CKD lead to poor outcomes. The Kidney Coordinated HeAlth Management Partnership (K-CHAMP) cluster randomized trial tested the effect of a population health management intervention versus usual care on CKD progression and evidence-based care delivery in the primary care setting.

Methods

K-CHAMP included adults aged 18–85 years with eGFR<60 ml/min per 1.73 m2 and moderate-high risk of CKD progression who were not seeing a nephrologist. The multifaceted intervention included nephrology e-consult, pharmacist-led medication management, and patient education. In this post hoc analysis, we evaluate the effectiveness of K-CHAMP on guideline-concordant care processes (BP and glycemic control, annual albuminuria testing) and medication exposure days (angiotensin-converting enzyme inhibitor [ACEi]/angiotensin receptor blocker [ARB], moderate-high intensity statin, sodium-glucose cotransporter-2 inhibitor [SGLT2i], glucagon-like peptide-1 receptor agonists [GLP-1RA]). Given multiplicity of outcomes, Benjamini–Hochberg method was used to control false discovery rate.

Results

All 1596 (754 intervention, 842 usual care) enrolled patients (mean age 74±9 years, eGFR 37±8 ml/min per 1.73 m2, 928 [58%] female, 127 [8%] Black) were analyzed. After a median 17-month follow-up, intervention arm patients had significantly higher exposure days per year to SGLT2i (56 versus 32 days; relative benefit 1.72; 95% confidence interval [CI], 1.14 to 2.30) and GLP-1RA (78 versus 29 days; relative benefit 2.65; 95% CI, 1.59 to 3.71) compared with usual care in adjusted analysis. At study initiation in 2019, similar proportion of patients were prescribed SGLT2i and/or GLP-1RA in intervention and control arm (8% versus 6%, respectively; rate ratio 1.23; 95% CI, 0 to 2.99), but by 2022, prescription of these medications was significantly higher in intervention arm (44% versus 27%, respectively; rate ratio 1.63; 95% CI, 1.32 to 1.94). There was no significant difference in any process measures or exposure days to ACEi/ARB in patients with albuminuria or moderate-high intensity statin.

Conclusions

K-CHAMP was effective in accelerating implementation of SGLT2i and GLP-1RA but did not increase ACEi/ARB in patients with albuminuria or moderate-high intensity statin use or improve BP control, glycemic control, or albuminuria testing in individuals with CKD in the primary care setting.

Clinical Trial registry name and registration number:

K-CHAMP, NCT03832595 .

Innovation in Providing Equitable Pre-exposure Prophylaxis Services in the United States: Expanding Access in Nontraditional Settings

BACKGROUND

Pre-exposure prophylaxis (PrEP) usage has slowly increased in the United States, but significant disparities persist across race, ethnicity, sex, gender, age, and geography. Determinants of PrEP inequities include stigma and medical mistrust, lack of patient-centered services, lack of access to clinical care, and organizational resistance to change-within a health care system that neglects these barriers.

METHODS

We describe 5 implementation strategies to providing PrEP in nontraditional settings to underserved populations, using an equity-based approach to address key structural determinants. The alternative settings used in these Ending the HIV Epidemic projects (community-based organizations, telePrEP, mobile clinics, pharmacies, emergency departments) were chosen for the setting characteristics and their serving structurally underserved populations.

RESULTS

Community-based organizations have earned trust within communities and can serve as hubs for comprehensive sexual health services, including PrEP. Telehealth, which expanded significantly because of COVID-19, can help overcome transportation and scheduling barriers to PrEP access. Mobile clinics can also broaden PrEP delivery by bringing tailored services directly to communities, often providing shorter wait times and extended hours. Pharmacists can prescribe PrEP in certain states through legislation or collaborative practice agreements, offering a convenient, community-based option. Emergency departments provide an alternative site for PrEP delivery, with the potential to reach individuals not currently engaged in regular care.

CONCLUSION

These alternative PrEP approaches can expand options for accessing PrEP and alleviate key barriers to care in traditional settings, although they may not eliminate all inequities. Offering more choices increases the likelihood that a broader population will be reached, thereby enhancing overall access to PrEP.

High-Volume Hemodiafiltration Versus High-Flux Hemodialysis: A Narrative Review for the Clinician

Background: End-stage kidney disease (ESKD) management presents a significant challenge, with increasing patient burden, escalating costs, and unmet needs in improving survival and quality of life. High-volume hemodiafiltration has been found to offer enhanced solute clearance, improved inflammatory marker profiles, and better patient-centered outcomes in multiple trials compared with high-flux hemodialysis. Recent data also confirm a survival advantage compared to standard high-flux hemodialysis. Methods: We compiled a narrative review for the clinician illustrating evidence supporting the comparative performance of high-volume hemodiafiltration with conventional high-flux hemodialysis in ESKD management. Data on intermediary outcomes including biochemical and clinical benefits, as well as patient-centered outcomes and all-cause and cardiovascular death data from prospective randomized trials, their meta-analyses, and real-world cohort studies were reviewed and summarized. Results: Randomized studies in adults have found that high-volume hemodiafiltration demonstrates superior outcomes, with a 23% improvement in survival rates when achieving convective volumes ≥23 L/session, enhanced removal of uremic toxins, reduced inflammation, and better patient-reported outcomes. Cohort studies in pediatric populations find associations with improvements in growth, cognitive development, and cardiovascular health. Hemodiafiltration appears to be cost-effective when accounting for extended life expectancy and improved quality of life, although the existing data are limited to European geographies. Conclusions: Hemodiafiltration offers enhanced survival, a reduced treatment burden, and improved quality of life for ESKD patients. Given the existing data of superiority versus high-flux hemodialysis, it is plausible that hemodiafiltration will become the standard of care.

Population Health Management for Improving Kidney Health Outcomes

Chronic kidney disease (CKD) is globally prevalent, a leading cause of mortality, and is associated with poor patient outcomes and high healthcare costs. Gaps in guideline-concordant care are common across the continuum of CKD. These gaps lead to CKD progression, hospitalizations, and mortality, and are potentiated by existing racial and socioeconomic disparities. A thoughtfully designed population health management approach, that leverages electronic health record, can modernize CKD care delivery and improve outcomes. Such an approach can potentially provide timely, equitable, resource- and cost-efficient care across health systems in a way that is scalable and data driven. Herein, we share our experiences with the implementation of nephrology population health initiatives at the University of Pittsburgh Medical Center across the CKD spectrum, which include ongoing and planned programs in the primary care, kidney-palliative care, kidney transplantation, and transitions of care settings. Further, we discuss the challenges of population health management and future directions that can move healthcare toward personalized medicine.

Impact of hospital-based early detection on management in chronic kidney disease: the CKD Stewardship study (CKD-S) - protocol for a prospective, multicentre, observational cohort study

INTRODUCTION

Chronic kidney disease (CKD) causes significant morbidity and mortality. Medical therapies can reduce the progression of disease by up to 50%. CKD is undiagnosed in the majority of people who have it, resulting in undertreatment. CKD Stewardship (CKD-S) aims to identify hospital inpatients with undiagnosed mid-stage to late-stage CKD with the goal of facilitating diagnosis and initiating guideline-based therapies.

METHODS AND ANALYSIS

This prospective, multicentre, cohort study compares two models of care, CKD-S and standard care, for identification and management of CKD, across six public hospitals in metropolitan Sydney, Australia. CKD-S entails active case finding using the electronic medical record, with nephrologist outreach to admitting teams and kidney nurse provided patient education. Adult inpatients with an admission estimated glomerular filtration rate (eGFR)<45 mL/min/1.73 m2 and not known to a nephrologist will be eligible, excluding those with short life expectancy or advanced age (>80 years). Participants will be enrolled between 1 March 2024 and 1 March 2025. Baseline and demographic data will be collected after discharge from the hospital. Participants will be followed up 12 months after discharge using Pharmaceutical Benefits Schedule and Medical Benefits Schedule data, linked via the Australian Institute of Health and Welfare Hub. We will report the proportion of all adults admitted to the hospital who are not already known to a nephrologist, in which a diagnosis of stage 3b-5 CKD is recognised by the CKD-S intervention team, compared with standard care. We will then compare the proportion in each cohort who have an eGFR or urine albumin:creatinine ratio measured, are referred to a nephrologist, and are prescribed guideline-directed therapies over the 12 months following discharge from the hospital.

ETHICS AND DISSEMINATION

The study has ethics approval from the Sydney Local Health District's Ethics Committee (Concord Hospital Zone). The results of the CKD-S study will be published in peer-reviewed journals and presented at academic conferences.

TRIAL REGISTRATION NUMBER

ACTRN12624000452594.

Are Your Kidneys Ok? Detect Early to Protect Kidney Health

Early identification of kidney disease can protect kidney health, prevent kidney disease progression and related complications, reduce cardiovascular disease risk, and decrease mortality. We must ask "Are your kidneys ok?" using serum creatinine to estimate kidney function and urine albumin to assess for kidney and endothelial damage. Evaluation for causes and risk factors for chronic kidney disease (CKD) includes testing for diabetes and measurement of blood pressure and body mass index. This World Kidney Day we assert that case-finding in high-risk populations, or even population level screening, can decrease the burden of kidney disease globally. Early-stage CKD is asymptomatic and simple to test for, and recent paradigm shifting CKD treatments such as sodium glucose co-transporter-2 inhibitors dramatically improve outcomes and favor the cost-benefit analysis for screening or case-finding programs. Despite this, numerous barriers exist, including resource allocation, health care funding, health care infrastructure, and health care professional and population awareness of kidney disease. Coordinated efforts by major kidney nongovernmental organizations to prioritize the kidney health agenda for governments and aligning early detection efforts with other current programs will maximize efficiencies.

Are your kidneys Ok? Detect early to protect kidney health

Early identification of kidney disease can protect kidney health, prevent kidney disease progression and related complications, reduce cardiovascular disease risk, and decrease mortality. We must ask "Are your kidneys ok?" using serum creatinine to estimate kidney function and urine albumin to assess for kidney and endothelial damage. Evaluation for causes and risk factors for chronic kidney disease (CKD) includes testing for diabetes and measurement of blood pressure and body mass index. This World Kidney Day we assert that case-finding in high-risk populations, or even population level screening, can decrease the burden of kidney disease globally. Early-stage CKD is asymptomatic and simple to test for, and recent paradigm shifting CKD treatments such as sodium glucose co-transporter-2 inhibitors dramatically improve outcomes and favor the cost-benefit analysis for screening or case-finding programs. Despite this, numerous barriers exist, including resource allocation, health care funding, health care infrastructure, and health care professional and population awareness of kidney disease. Coordinated efforts by major kidney nongovernmental organizations to prioritize the kidney health agenda for governments and aligning early detection efforts with other current programs will maximize efficiencies.

Global Policy and Advocacy Initiatives for Improving Kidney Care: Report from the 2023 International Society of Nephrology Global Kidney Health Atlas

Key Points

Inclusion and prioritization of CKD and kidney failure within national health strategies are generally lacking. Countries with CKD-specific strategies tend to include and fund a broader spectrum of kidney disease populations and kidney care. Greater global and national prioritization of kidney health are required to reduce global inequities in access to kidney care.

Background

National strategies to address CKD are crucial to support kidney health. Lack of political support in the form of policy decisions and funding leads to fragmentation of kidney care and catastrophic health expenditure. This study used data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas to obtain a global overview of the existence and reach of national strategies for kidney care.

Methods

We leveraged data from an international survey of stakeholders (clinicians, policymakers, and patient advocates) conducted by the International Society of Nephrology between July and September 2022. Data were extracted on existence and scope of national noncommunicable disease (NCD) and/or CKD-specific strategies and policies, as well as recognition of kidney disease as a national health priority through participant perception and existence of CKD advocacy groups.

Results

Overall, stakeholders from 167 countries responded to the survey, representing 97.4% of the global population. National strategies for NCDs were reported by 56% of countries. In 29% of countries, CKD was addressed within an NCD strategy, whereas 25% of countries reported CKD-specific strategies. Countries with CKD-specific strategies were more likely to address all CKD populations (non–dialysis-dependent CKD, chronic dialysis, and kidney transplantation) compared with those with NCD strategies only (51.2% versus 19%). Of the 54% of countries with any CKD strategy, 89% reported public funding of the full spectrum of CKD care compared with 64% of those with no CKD strategy. Kidney failure, CKD, and AKI were reported to be recognized as national health priorities by 63%, 48%, and 19% of countries, respectively.

Conclusions

The inclusion of CKD and kidney failure within national health strategies is frequently lacking. Countries with CKD-specific policies tend to include a broader spectrum of kidney disease populations and to fund kidney care more than those with CKD policies integrated within NCD strategies. Greater global and national prioritization of kidney health are required to reduce global inequities in access to kidney care.

Combination therapy: an upcoming paradigm to improve kidney and cardiovascular outcomes in chronic kidney disease

In this article the authors review recent advances in the treatment of chronic kidney disease (CKD) with diabetes, and summarize evidence supporting combination therapy approaches to improve patient outcomes. Driven by the global rise in diabetes, the worldwide burden of CKD has nearly doubled since the 1990s. People with CKD have notably increased risks for premature cardiovascular disease (heart and blood vessels disease), kidney failure and death. CKD, diabetes, obesity and cardiovascular disease are closely interrelated and share common risk factors. These health conditions therefore comprise what is now known as cardiovascular-kidney-metabolic (CKM) syndrome. Recently approved medications, including sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and the non-steroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone, represent agents capable of reducing metabolic, kidney and cardiovascular risk through complementary mechanisms of action. Current evidence supports use of these therapies in combination. Besides providing additive protective effects, combination therapy may also help reduce side effects. For instance, using an SGLT2 inhibitor in combination with finerenone helps decrease the risk for high potassium levels. Through the multipronged approach, combination therapy allows tailoring treatment for the individual patient characteristics and needs. Several planned and ongoing clinical trials continue to study the benefits of combination therapy in people with CKM syndrome. With building evidence supporting the use of combination therapy, it is crucial to raise awareness of the importance of this treatment approach and develop processes to incorporate new therapies into every day practice to support optimal care and improved outcomes.

ABSTRACT

The global burden of chronic kidney disease (CKD) increased by nearly 90% in the period spanning 1990 to 2016, mostly attributed to an increase in the prevalence of CKD in diabetes. People living with CKD have an elevated lifetime risk for cardiovascular disease (CVD) when compared with the general population, with risk increasing in parallel with albuminuria and kidney function decline. Metabolic disease, CKD and CVD share common risk factors including neurohumoral activation, systemic inflammation and oxidative stress, thus prompting the introduction of a broader construct of cardiovascular-kidney-metabolic (CKM) syndrome. An important rationale for the introduction of this concept are recent and ongoing therapeutic advancements fundamentally changing CKM management. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and the non-steroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone have shifted the therapeutic paradigm for patients with CKD and have emerged in rapid succession as cornerstones of guideline-directed medical therapy (GDMT). Recently completed clinical trials of aldosterone synthase inhibitors and endothelin receptor antagonists have additionally reported additive antiproteinuric effects on the background of renin-angiotensin system and SGLT2 inhibition, with acceptable safety profiles. The sum of current evidence from both preclinical and clinical studies support combination therapy in the setting of CKD to achieve additive and potentially synergistic kidney and heart protection by addressing metabolic, hemodynamic, and pro-inflammatory and pro-fibrotic mechanistic pathways. This narrative review will discuss available evidence supporting combination GDMT in CKD with diabetes and additionally discuss ongoing and future trials evaluating the efficacy and safety of combination therapies for CKD with or without diabetes.

KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease in Children and Adults: a commentary from the European Renal Best Practice (ERBP)

The Kidney Disease: Improving Global Outcomes (KDIGO) 2024 Guideline for Identification and Management of Chronic Kidney Disease (CKD) is a welcome development, coming 12 years after the paradigm-changing 2012 guidelines. We are living in an unprecedented era in nephrology with novel therapies, including sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists, now being proven in multiple randomized controlled clinical trials to reduce both the progression of CKD and cardiovascular morbidity and mortality. The KDIGO 2024 CKD Guideline is aimed at a broad audience looking after children and adults with CKD and provide practical and actionable steps to improve care. This commentary reviews the guideline sections pertaining to the evaluation and risk assessment of individuals with CKD from a European perspective. We feel that despite the last guideline being published 12 years ago, and the fact that the assessment of CKD has been emphasized by many other national/international nephrology, cardiology and diabetology guidelines and societies, the diagnosis and treatment of CKD remains poor across Europe. As such, the KDIGO 2024 CKD Guideline should be seen as an urgent call to action to improve diagnosis and care of children and adults with CKD across Europe. We know what we need to do. We now need to get on and do it.

Chronic kidney disease

Chronic kidney disease (CKD) is defined by persistent abnormalities of kidney function or structure that have consequences for the health. A progressive decline of excretory kidney function has effects on body homeostasis. CKD is tightly associated with accelerated cardiovascular disease and severe infections, and with premature death. Kidney failure without access to kidney replacement therapy is fatal - a reality in many regions of the world. CKD can be the consequence of a single cause, but CKD in adults frequently relates rather to sequential injuries accumulating over the life course or to the presence of concomitant risk factors. The shared pathomechanism of CKD progression is the irreversible loss of kidney cells or nephrons together with haemodynamic and metabolic overload of the remaining nephrons, leading to further loss of kidney cells or nephrons. The management of patients with CKD focuses on early detection and on controlling all modifiable risk factors. This approach includes reducing the overload of the remaining nephrons with inhibitors of the renin-angiotensin system and the sodium-glucose transporter 2, as well as disease-specific drug interventions, if available. Hypertension, anaemia, metabolic acidosis and secondary hyperparathyroidism contribute to cardiovascular morbidity and reduced quality of life, and require diagnosis and treatment.

Representation of Low- and Middle-Income Countries in CKD Drug Trials: A Systematic Review

RATIONALE & OBJECTIVE

Almost 80% of individuals with chronic kidney disease (CKD) reside in low- and middle-income countries (LMICs) and are potentially underrepresented in randomized controlled clinical trials (RCTs). We assessed the global distribution of RCTs comparing pharmacological treatments for CKD over the past 2 decades, as well as the magnitude and evolution of participation by LMICs.

STUDY DESIGN

Systematic review.

SETTING & STUDY POPULATIONS

RCTs evaluating pharmacological interventions in adults with CKD.

SELECTION CRITERIA FOR STUDIES

RCTs published between 2003-2023 and indexed in MEDLINE.

DATA EXTRACTION

Each trial was reviewed and extracted independently by 2 investigators with disagreements settled by consensus or a third reviewer.

ANALYTICAL APPROACH

RCT participation of World Bank-defined income groups and geographic regions were described, and the representation indices (RI) according to RCT participants and estimated CKD prevalences were calculated. RCTs were also categorized as global, regional, or national in scope.

RESULTS

Among 7,760 identified studies, we included 1,366 RCTs conducted in 84 countries with 301,158 participants. National, regional, and global RCTs represented 85.4%, 3.5%, and 11.1% of studies, respectively. LMICs were included in 34.7% of RCTs. No RCTs included participants from low-income countries, and lower-middle-income countries participated in 13.2%. Of participants from RCTs with available information, 25.4% (n=64,843 of 255,237) were from LMICs. According to the RI, 6 LMICs were overrepresented (>1.25), 7 were adequately represented (0.75-1.25), and 26 were underrepresented (<0.75). Most global CKD RCTs (80.2%) included LMICs; however, LMIC participants constituted only 32.9% of the global trial population. We observed a positive trend in LMIC inclusion over time, rising from 22.9% (n=71of 310) in 2003-2007 to 45.5% (n=140of 308) in 2018-2023.

LIMITATIONS

The use of an income-group dichotomy, exclusion of nonrandomized studies of intervention, and studies identified in 1 database.

CONCLUSIONS

Despite an increase in participation over the past 2 decades, individuals with CKD from LMICs remain significantly underrepresented in RCTs. These findings suggest that increased efforts are warranted to increase LMIC representation in pharmacological CKD RCTs.

PLAIN-LANGUAGE SUMMARY

Chronic kidney disease (CKD) substantially affects people from low- and middle-income countries (LMICs). However, the participation of these countries in randomized controlled trials (RCTs) remains uncertain. To assess the global distribution and representation of these countries in kidney disease research, we reviewed 1,366 CKD drug RCTs published from 2003-2023, conducted in 84 countries involving more than 300,000 participants. LMICs were included in approximately a third of these studies, with their participants making up approximately one-quarter of the total; lower-middle-income countries were poorly represented, and low-income countries were absent. LMICs constituted a third of participants in multinational RCTs. Most LMICs were underrepresented relative to the prevalence of CKD. We observed an increasing inclusion of LMICs, particularly in the last decade. Nonetheless, individuals with CKD from LMICs remain underrepresented in drug RCTs, suggesting that increased efforts are warranted to include representation of these populations in these studies.

Referral, monitoring, and factors associated with non-referral of chronic kidney disease in Germany: a nationwide, retrospective cohort study

Background

Chronic kidney disease (CKD) is one of the most significant drivers of the global burden of disease and an increasing public health issue. Adequate monitoring and referral of high-risk patients to nephrologists are associated with improved management of CKD. We aimed to assess nephrology referral rates, monitoring of kidney function, and factors associated with failure to refer in Germany.

Methods

We retrospectively analyzed ambulatory claims data of 73,675,956 German patients who were covered by statutory health care in 2022, building a cohort of 1,301,122 patients who had at least two diagnoses of CKD stage 3-5 within the calendar year. In our analysis, we focused particularly on patients with CKD stage 4.

Findings

We identified 207,043 patients with CKD stage 4, of which 134,143/207,043 (64.8%) received nephrologist treatment in 2022. The median age of the cohort was 82 years. Failure to quantify proteinuria occurred in 61,991/72,900 (85.0%) non-referred patients compared to 51,382/134,143 (38.3%) referred patients. In a mixed logistic regression model, referral was less likely for women (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.71-0.74), higher age (OR per year 0.97, CI 0.96-0.97), nursing home inhabitants (OR 0.63, CI 0.61-0.65), and those with certain comorbidities. Regional factors (deprivation, population density, nephrologist density) were not associated with referral.

Interpretation

A substantial proportion of patients with late-stage CKD are not receiving guideline-recommended kidney care in the German health care system, with disparities driven primarily by individual patient factors rather than geographical barriers.

Funding

This study was funded by the University Hospital Schleswig-Holstein and the Central Research Institute of Ambulatory Health Care in Germany.

An overview of the CANVAS Program and CREDENCE trial: The primary outcomes and key clinical implications for those managing patients with type 2 diabetes

AIMS

To provide an overview of the primary outcomes and key clinical implications of the CANVAS Program and CREDENCE trial, which were event-driven, double-blind randomized controlled trials that established the efficacy and safety of canagliflozin in those with type 2 diabetes (T2D) and high cardiovascular risk (CV) or albuminuric chronic kidney disease (CKD).

METHODS AND RESULTS

The CANVAS programme (CANVAS and CANVAS-R trials) randomized 10 142 people with T2D and high CV risk to canagliflozin or placebo and followed them for a median of 126 weeks. The primary efficacy outcome was met, with canagliflozin treatment associated with a 14% reduction in major adverse CV events (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.75 to 0.97; p < 0.001) as compared to placebo. The CREDENCE trial randomized 4401 individuals with T2D and albuminuric CKD to canagliflozin or placebo and followed them for 109 weeks. The CREDENCE trial also met its primary endpoint; canagliflozin treatment was associated with a 30% reduction in the composite of kidney failure, sustained doubling of serum creatinine level, or death from kidney or CV causes (HR 0.70, 95% CI 0.59 to 0.82; p < 0.001). Substantial reductions in hospitalization for heart failure (CANVAS: HR 0.67, 95% CI 0.52 to 0.87; CREDENCE: HR 0.61, 95% CI 0.47 to 0.80) and other key CV and kidney outcomes were also identified. Relative clinical benefits were consistent across subgroups defined by baseline age, sex, kidney function and history of CV disease but absolute benefits were greatest in those at highest baseline risk. Total serious adverse events were less common with canagliflozin treatment. Concerns about amputation and fracture risk observed in the CANVAS Program were not seen in CREDENCE and appear to have been spurious chance findings.

CONCLUSION

Canagliflozin reduced important CV, kidney and mortality outcomes in those with T2D and high CV risk or CKD across diverse patient groups, with a good safety profile. Taken together with the other sodium-glucose cotransporter-2 inhibitor CV and renal outcomes trials, these landmark findings have changed the treatment landscape for patients worldwide.