Influence of guideline adherence and parameter control on the clinical outcomes in patients with diabetic nephropathy

We assessed the association between guideline adherence and outcomes of clinical parameter control and end-stage kidney disease (ESKD), and further studied the effect of parameter control on ESKD for Chinese patients with diabetic nephropathy (DN).

In this retrospective study, 1128 patients with DN (15,374 patient-visit samples) diagnosed by renal biopsy were enrolled. Samples were classified as adherence and nonadherence based on whether prescribed drugs conformed to medication regimen and drug contraindication recommended by guidelines, including American Diabetes Association (ADA) and Chinese guidelines. Guideline adherence rate was calculated on all samples for antihyperglycemic, antihypertensive and lipid-lowering treatments. Clinical parameter control was compared after 3-6 months' therapy between two groups by generalized estimating equation models. Time-dependent Cox models were applied to evaluate the influence of guideline adherence on ESKD. Latent class mixed model was used to identify distinct trajectories for parameters and their ESKD risks were compared using Cox proportional-hazards models.

Guideline adherence rate of antihyperglycemic therapy was the highest, with 72.87% and 68.15% of samples meeting ADA and Chinese guidelines, respectively. Adherence was more likely to have good glycated hemoglobin A1c (HbA1c) control (ADA: OR 1.46, 95% CI 1.12 to 1.88; Chinese guideline: OR 1.42, 95% CI 1.09 to 1.85) and good blood pressure control (ADA: OR 1.35, 95% CI 1.03 to 1.78; Chinese guideline: OR 1.39, 95% CI 1.08 to 1.79) compared with nonadherence. The improvement of patient's adherence showed the potential to reduce ESKD risk. For proteinuria, low-density lipoprotein cholesterol (LDL-C), systolic blood pressure and uric acid, patients in higher-value trajectory group had higher ESKD risk. Proteinuria and LDL-C trajectories were most closely related to ESKD risk, while the risk was not significantly different in HbA1c trajectories.

Guideline adherence and good control of proteinuria and LDL-C in clinical practice are important and in need for improving clinical outcomes in patients with DN.