Few patients with diabetic kidney disease (DKD) are receiving guideline-recommended protective therapies, a new study suggests, highlighting missed opportunities to improve their care.

“We are experiencing a shifting landscape, with several new renoprotective treatments approved in the past few years, and potentially more to come in the near future,” Csaba Kovesdy, MD, of the University of Tennessee in Memphis, told Renal & Urology News. “Our data from 2018-2019 suggests that the application of ‘traditional’ renoprotective therapies is insufficient, which creates a significant unmet need for these newer therapies.”

Guideline-Recommended Treatments Underused

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Using the US-based Optum Clinformatics™ Data Mart, Dr Kovesdy and his team studied administrative claims from January 1, 2007 and March 31, 2019 to gauge use of antihypertensive drugs, such as angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), and steroidal mineralocorticoid receptor antagonists (sMRAs), as well as use of antidiabetic agents, such as sodium-glucose cotransporter 2 inhibitors (SGLT2is), dipeptidyl peptidase-4 inhibitors (DPP4is), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), insulin, and sulfonylureas. Current treatment guidelines from the Kidney Disease Improving Global Outcomes (KDIGO) initiative suggest treating hypertension with a renin-angiotensin system (RAS) blocker. Recommended first-line antihyperglycemic treatment includes metformin and SGLT2i. If glycemic targets are not met, combination therapy with other glucose-lowering drugs are considered, such as GLP-1 RA, DPP4i, sulfonylureas, or insulin.

Dr Kovesdy’s team observed low initiation and high discontinuation rates among the 63,127 patients with type 2 diabetes with newly developed chronic kidney disease, according to study findings published in Nephrology Dialysis Transplantation. Initiation and discontinuation rates were 17.8% vs 56.0% for ACEi/ARBs; 1.3% vs 66.0% for sMRAs; 2.5% vs 65.0% for SGLT2is; 3.7% vs 66.8% for DPP4is; 2.31% vs 69.0% for GLP-1 RAs, 4% vs 75.7% for insulin; and 5.5% vs 56.9% for sulfonylureas, respectively. The investigators observed similar trends for subgroups with uncontrolled hyperglycemia, rapid progression (5 mL per year or more decline in estimated glomerular filtration rate [eGFR]), advanced CKD, cardiovascular disease (CVD), and anemia.

Few patients were prescribed SGLT2i and GLP-1 RA during the year prior to CKD diagnosis, the investigators pointed out, while all antihypertensive drugs were used more often in patients with preexisting CVD.

In an interview, Dr Kovesdy highlighted that treatment patterns since 2018-2019 are changing dynamically as a result of newer renoprotective medications, such as finerenone, a new nonsteroidal MRA, and a gradual expansion of indications, such as the use of SGLT2is in nondiabetic patients.

“There are plenty of opportunities with the newer agents,” he said. “I expect a shift to continue, such as approval of other nonsteroidal MRAs, the expansion of nonsteroidal MRAs to nondiabetic patients, and the application of combination regimens like nonsteroidal MRA+SGLT2i.

“Challenges include the cost of newer agents and the lack of clinical trials for many of the practical questions we are still facing,” he continued. “For example, are these agents effective in patients with even lower eGFR and albuminuria levels? What drug combination is optimal? Can newer agents be used in patients with any kind of nondiabetic CKD, or only certain etiologies?”

Clinical Outcomes and Costs

According to Dr Kovesdy, high-risk patients may benefit from further treatment options to improve mortality and morbidity and reduce the economic burden of health care. His team examined clinical and economic outcomes among a prevalent cohort of 326,763 patients with type 2 diabetes and any CKD.

All-cause and cardiovascular hospitalization rates were 283.14 and 78.32 per 1000 person-years, respectively. The rate of end-stage kidney disease (ESKD) was 104.19 per 1000 person-years, compared with a kidney transplantation rate of 2.17 per 1000 person-years. The all-cause mortality rate was 35.07 per 1000 person-years.

Higher rates of all-cause and cardiovascular-related hospitalizations, kidney outcomes, and all-cause mortality were found for patients with rapid CKD progression and advanced CKD.

In the prevalent cohort, total health care costs were a mean $29,377 per year overall, with higher costs for patients with later stages of CKD ( (from $30,770 for those with stage 3B to $184,159 for those with stage 5).

Disclosure: This research was supported by Bayer AG. Please see the original reference for a full list of disclosures.


Fried L, Schmedt N, Folkerts K, et al. High unmet treatment needs in patients with chronic kidney disease and type 2 diabetes: real-world evidence from a US claims database. Nephrol Dial Transplant. Published online April 7, 2022. doi:10.1093/ndt/gfac140