Missing Opportunity for Nephroprotective Therapy in Patients With Non-Dialysis CKD Under Stable Nephrology Care

Awareness of the implementation of guideline-directed nephroprotective therapy is an essential preliminary step to optimize implementation of nephroprotective strategies in nondialysis chronic kidney disease (CKD) (ND-CKD). However, updated information on this issue is lacking in the setting of nephrology clinics.

In this multicenter prospective study, we collected data from 4523 patients with ND-CKD, either stage 3 to 5 or 1 and 2 with urinary albumin-to-creatinine ratio (ACR) > 30 mg/g, followed up in 30 Italian nephrology clinics. Patients were evaluated at 2 visits with a 6-month interval between May 2024 and May 2025. The aim was to evaluate the current phenotype of patients under tertiary nephrology care and the management of the 2 major modifiable determinants of renal risk, hypertension and ACR, including therapeutic inertia.

The cohort was characterized by a severe cardiorenal risk profile: men comprised 65% of the cohort, mean age was 71 ± 14 years, diabetes was present in 40%, cardiovascular disease in 40%, estimated glomerular filtration rate (eGFR) was 34 ± 19 ml/min per 1.73 m², and ACR was 70 mg/g (interquartile range: 11-350). At the 6-month visit, in patients with and without diabetes, home and office blood pressure (BP) were above target in about 70% of patients, with a high prevalence of sustained (62%) and resistant (23%) hypertension. Among patients with uncontrolled office BP, 33% and 43% of patients with and without diabetes, respectively, were prescribed ≤ 2 BP-lowering drugs. ACR > 30 mg/g persisted in 61% of nondiabetic and 64% of patients with diabetes. Therapeutic inertia for antialbuminuric agents at month 6 was frequent: 85% for renin-angiotensin system (RAS) inhibitors and 90% for gliflozins. Among patients with diabetes, therapeutic inertia was 92% for glucagon-like peptide-1 receptor agonists (GLP1-RAs) and 96% for finerenone.

The large majority of patients with ND-CKD currently followed up in Italian renal clinics are characterized by a severe risk profile that is paradoxically associated with remarkable therapeutic inertia for both traditional and innovative guideline-directed nephroprotective therapy.