Risk-directed management of chronic kidney disease
A review argues that chronic kidney disease should be managed by prognosis: using modern risk-prediction tools to direct the four pillars of therapy (RAS inhibitors, SGLT2 inhibitors, GLP-1 receptor agonists, and mineralocorticoid receptor antagonists) to the patients most likely to benefit, since these effective drugs remain underused.
Background
CKD is heterogeneous in cause and trajectory, carrying risks of kidney failure as well as cardiovascular events and death. The past decade has brought major advances in both risk prediction (aided by electronic health records) and effective therapies, creating an opportunity to match treatment to individual risk.
Key points
Large randomized trials established SGLT2 inhibitors, GLP-1 receptor agonists, and mineralocorticoid receptor antagonists as effective in reducing adverse CKD outcomes; together with ACE inhibitors and angiotensin-receptor blockers, these are framed as the four pillars of CKD pharmacotherapy. Yet all are underutilized, even among high-risk patients. Prognostic estimates can identify those most likely to benefit, aligning patient risk with care and prioritizing absolute benefit in therapy selection and timing.
Clinical implications
Adopting a risk-directed, prognosis-guided strategy — rather than uniform stepwise care — could close the gap between available evidence-based therapies and their real-world use, ensuring high-risk CKD patients receive the pillars of treatment earlier and improving kidney and cardiovascular outcomes.
Category
Research
Source
Nature Reviews Nephrology
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