CKD-guideline adherence in primary and nephrology care for older patients with advanced CKD

Older patients with chronic kidney disease (CKD) often experience relatively slow kidney function decline, suggesting that, despite meeting referral criteria, primary care management may be appropriate. We assessed guideline recommended CKD management in patients with CKD stage 4-5 across primary and nephrology care.

Population-based study using routine healthcare data from primary care and hospitals, including patients ≥ 65 years with incident or prevalent eGFR <30 ml/min/1.73m2 between 2015 and 2024. Guideline adherence was evaluated using thirteen quality indicators, calculated as the proportion of patients fulfilling these indicators or the proportion of follow-up time covered by adherent care.

Of 1969 patients (mean age 81.8 years, median eGFR 25 ml/min/1.73m2), 61.2% were managed in primary care. These patients were older and were more often considered frail. In primary care, monitoring covered 82.5% of follow-up time for kidney function, 47.8% for albuminuria, 76.6% for blood pressure, 85.6% for haemoglobin, 50.9% for LDL-cholesterol and 68.3% for HbA1c among patients with diabetes. Corresponding estimates in nephrology care were 86.8%, 65.2%, 84.4%, 97.5%, 68.3% and 84.9%, respectively. Monitoring of metabolic complications, which falls beyond primary care guidelines, was 28.4%-79.2% in primary care and 73.6%-97.8% in nephrology care. RAAS inhibitors were prescribed in 56.9% (primary care) and 84.4% (nephrology care); SGLT2 inhibitors in 4.3% and 10.1%, and NSAIDs in both settings < 7%. Guideline adherence did not vary by socio-economic status or country of origin. In primary care, adherence was higher in patients with diabetes.

The majority of older patients with CKD stage 4-5 are managed in primary care. Guideline adherence varied across care settings, which served substantially different patient populations. Higher adherence in patients with diabetes, typically enrolled in structured disease management programs, suggests that embedding similar structured approaches may enhance adherence to CKD guideline in primary care.