Making treatment guideline recommendations in chronic kidney disease and type 2 diabetes more accessible to primary care providers in the United States

ABSTRACT

Clinical practice guidelines for the management of chronic kidney disease (CKD) associated with type 2 diabetes (T2D) are designed to assist healthcare professionals with clinical decision making by providing recommendations on the screening, detection, management, and treatment of these conditions. However, primary care practitioners (PCPs) may have clinical inertia when it comes to routinely enacting CKD and T2D guideline recommendations in their clinical practices. Guideline developers have published a range of resources with the aim of facilitating easier access to guideline recommendations to support efficient and consistent implementation into clinical practice of PCPs. Challenges remain in providing strategies to reduce inertia in the application of guideline recommendations in primary care. In this review, we explore reasons behind the low level of awareness and poor uptake of published evidence-based care approaches to the optimal management of patients with T2D and CKD. Finally, we present suggestions on strategies to improve the implementation of guideline-directed recommendations in primary care.

Plain Language Summary

Clinical practice guidelines for managing chronic kidney disease (CKD) for people who also have type 2 diabetes (T2D) provide healthcare providers with recommendations on how to identify, diagnose, and treat CKD. Although treatments cannot cure CKD, they can help to reduce the risk of CKD getting worse. The recommendations are based on results of clinical trials that tested how safe and how well a medication works among many people with CKD and T2D. If these clinical trials show that the medicine is beneficial for people with CKD and T2D, then it may be included in guideline recommendations. Most people living with T2D and early-stage CKD are treated by their primary care practitioner (PCP). If PCPs are not fully aware of guideline recommendations, then their patients may lose the opportunity to receive medications that can benefit them. PCPs have said that barriers to implementing guideline recommendations in their clinical practices include too many guidelines and that the guidelines are difficult to understand and use in their offices. Guideline developers have thought of ways to make the guidelines easier to access and use. This includes putting the guidelines onto mobile apps, providing online resources, making versions more relevant to PCPs, and combining multiple guidelines. These approaches are helpful, but more work is needed. This review article talks about the reasons why PCPs are not always aware of the most up-to-date guideline recommendations for CKD and T2D, how guideline developers have found different ways of sharing the guideline recommendations, and what more can be done.

Graphical abstract

KEYWORDS:

• Chronic kidney disease
• type 2 diabetes
• clinical practice guidelines
• guideline implementation
• primary care
• clinical decision making

1. Introduction

Chronic kidney disease (CKD) is a common and serious condition that affects nearly 40% of people with type 2 diabetes (T2D) in the United States (US) [1]. CKD is often asymptomatic until it becomes advanced, posing challenges for early detection and optimal management [2]. Advanced CKD (stages 4 and 5) is associated with high morbidity and mortality, primarily due to cardiovascular complications [3,4]. The pathologic interconnectivity between the heart, the kidneys and metabolic disease in conditions such as CKD (referred to as cardiovascular-kidney-metabolic [CKM] syndrome) has been recognized and described [5]. Kidney damage from CKD is irreversible, particularly in the advanced stages; therefore, the aim of treatment is to reduce the risk of CKD, and to slow CKD progression, and the development of associated comorbidities, such as cardiovascular disease (CVD) [6]. To facilitate the early detection and management of CKD, clinical practice guidelines for CKD associated with T2D (for example, the Kidney Disease Improving Global Outcomes [KDIGO] 2024 Clinical Practice Guideline For the Evaluation and Management of CKD, the KDIGO 2022 Clinical Practice Guidelines for Diabetes Management in CKD, and the American Diabetes Association [ADA] 2024 Standards of Care in Diabetes [Chapter 11]) are intended to assist healthcare professionals (HCPs) with clinical decision making by providing evidence-based recommendations on detection, monitoring, and treatment of CKD associated with T2D [7–9]. A coordinated multidisciplinary team (MDT) approach (involving members of the wider care team, such as educators, nurses, and clinical pharmacists) is recommended to ensure that patients with CKD and T2D receive guideline-directed medical therapy with the aim of delaying CKD progression and improving cardiovascular outcomes [10,11]. A MDT approach is described in both KDIGO 2024 (focused on CKD) and KDIGO 2022 (focused on diabetes and CKD) Clinical Practice Guidelines [8,9].

Most patients with T2D and CKD are managed in primary care, unless they develop complications or their kidney function worsens, in which case they may be referred to specialist services. There is an ongoing effort to encourage primary care practitioners (PCPs) to perform routine screening to enable early diagnosis of CKD, and to follow treatment guideline recommendations in order to improve overall CKD care and management [8,12]. PCPs are encouraged to decide how best to apply CKD guideline recommendations into their own clinical practice by using available resources [8,9]. However, there are several barriers to implementing guideline recommendations in clinical practice, such as lack of awareness of CKD guidelines or awareness of useful algorithms for CKD care, as well as poorly accessible guidelines (due to too much detail) and lack of contemporary mobile apps or internet-based resources [13,14].

In this review, we explore the reasons behind the therapeutic inertia to implementation of guidelines by PCPs, which are intended to optimize the care of patients with CKD and T2D. Furthermore, we offer suggestions on strategies that could be used to increase the application of guideline-directed medical therapies in primary care. Lastly, we have developed visual clinical decision support aids that include sample visual clinical care pathways that reflect the KDIGO heat map from the ADA-KDIGO consensus report [15], and a hypothetical patient clinical profile, to support the decision-making process.

2. Low awareness and suboptimal implementation of CKD treatment guideline recommendations by PCPs

The majority of patients with T2D associated with CKD are initially encountered by PCPs. As such, PCPs are ideally positioned to screen, diagnose, and initiate timely management of early stages of CKD in patients with T2D. Despite this, several studies have shown that physician awareness and knowledge of clinical practice guidelines for these patients is suboptimal [14,16]. Research has shown that many PCPs do not routinely follow or implement CKD guideline recommendations, despite resources that are available to them [14,17–19]. For example, a mixed methods study (analyzing both qualitative and quantitative data) involving 32 community-based PCPs across four cities in the US found that 45% of PCPs reported not following CKD guidelines [14]. In our opinion, ideally all PCPs who care for patients with CKD should follow published guidelines.

The lack of adherence is also evident in research showing that guideline-recommended drug treatments that have proven benefit in CKD and T2D are under-prescribed. For instance, in 2022, a retrospective cohort study involving 7199 patients with CKD and T2D found that 42% were not prescribed a renin-angiotensin-aldosterone system (RAAS) inhibitor and 80.3% were not prescribed a sodium glucose cotransporter-2 (SGLT2) inhibitor [19], despite recommendations for these types of drugs to delay CKD progression in patients with CKD and T2D [7–9]. This suggests that suboptimal recognition of CKD may be a potential cause to the limited use of these medications for blood pressure control and blood glucose management [19]. Additionally, a study using a national claims database of patients with commercial health insurance or Medicare Advantage insurance found that of the 31,690 patients with CKD who met guideline-recommended criteria for referral to nephrology, only 55% were seen by a nephrologist [17]. This may demonstrate the need to increase guideline awareness and implementation in primary care, especially where clinical evidence suggests such recommendations are beneficial and significantly improve clinical outcomes for patients with CKD and T2D.

2.1. Uncertainty among PCPs about the selection and timing of prescribing CKD-slowing drugs

The KDIGO 2022 (diabetes and CKD focus) and 2024 (CKD focus) Clinical Practice Guidelines and the 2024 ADA Standards of Care provide recommendations to HCPs on strategies to slow CKD progression and improve cardiovascular risk reduction in patients with CKD and T2D that are based on the results of large randomized, controlled clinical trials [7,8]. Importantly, SGLT2 inhibitors and the nonsteroidal mineralocorticoid receptor antagonist (ns-MRA) finerenone have proven kidney and cardiovascular protective benefits and indication [20–26]. SGLT2 inhibitors and finerenone can be taken together, although in the large phase 3 trials with finerenone, fewer than 10% of participants were taking a SGLT2 inhibitor, and both those taking a SGLT2 inhibitor and those not taking a SGLT2 inhibitor benefited from finerenone (versus placebo) [20,26,27]. Another drug class, the glucagon-like peptide 1 receptor antagonists (GLP1 RAs) have already shown cardiovascular protective effects, and may potentially also have renal benefits when added to standard of care [28–30]. Although some PCPs still limit the use of SGLT2 inhibitors as antihyperglycemic agents [31], and other PCPs may not fully appreciate the indications and differences in the mechanism of action (MOA) between the ns-MRA finerenone and the steroidal MRAs [32] spironolactone and eplerenone. Steroidal MRAs are indicated for the management of patients with resistant hypertension, hyperaldosteronism, heart failure, and/or edema [33,34] and may have a greater hyperkalemia risk potential compared with the ns-MRA finerenone [35]. Steroidal MRAs have no indication for CKD treatment.

2.2. PCP selectivity regarding specific aspects of the guideline recommendations

Adherence to recommendations for CKD screening appears to be selective in that some physicians may follow specific aspects of the recommendations while ignoring other features [16]. For example, some physicians use only serum creatinine (or estimated glomerular filtration rate [eGFR]) as a measure of renal function [17], even though the ADA-KDIGO consensus report recommends that patients should be screened for CKD using laboratory tests for both eGFR and urine albumin-to-creatinine ratio (UACR) at the time of diagnosis of T2D and at least annually [15]. A study using a US administrative claims database of 1,881,447 patients with T2D found that although patients had a diagnosis of CKD based on their GFR, less than half (43.3%) were also screened for albuminuria, by UACR, during the first year of their diagnosis of T2D [36]. Inconsistent uptake of guideline recommendations may be a result of limited awareness of specific portions of the guidelines [16]. For example, physicians have reported a lack of familiarity with the guidelines, beyond using them to diagnose patients with the correct CKD stage [16]. The lack of appropriate implementation of guideline recommendations may indicate guideline fatigue, which refers to the inconsistent application of recommendations due to an abundance of guidelines [37]. For example, in addition to the KDIGO and ADA guidelines, the American College of Physicians, the American Family Physician, and the US Preventive Services Task Force have similarly published guidance on screening and management of CKD [38–40].

2.3. Potential impact on patients due to limited implementation of guideline recommendations

Limited implementation of guideline recommendations may lead to detection of CKD being delayed until more advanced CKD has developed. More advanced stages of CKD are more difficult to manage and are associated with more complex comorbidities and poorer clinical outcomes [41,42]. Indeed, 90% of adults with CKD in the US are unaware they have CKD, and as many as 1 in 3 have severe CKD without knowing that they have CKD [43]. In addition, patients with CKD and T2D may not receive timely guideline-recommended treatments, which have proven benefit to slow CKD progression and improve overall clinical outcomes. Patients may benefit from CKD-focused treatments irrespective of their pre-treatment UACR. Although, there could be confusion regarding the sequence of therapies for certain UACR and eGFR thresholds; the KDIGO 2024 and 2022 guidelines and the ADA-KDIGO consensus report base their treatment initiation recommendations for SGLT2-inhibitors in patients who also have T2D on eGFR without reference to the UACR level [8,9,15]. However, the UACR supports risk stratification and provides a foundation for initiation of the ns-MRA finerenone when indicated.

3. Efforts to make guideline recommendations more accessible

3.1. Consensus report to align treatment guideline recommendations

In the arena of therapies for CKD associated with T2D, there are multiple treatment guidelines that offer slightly different perspectives. Incongruous guideline recommendations can cause confusion and uncertainty for PCPs and be an obstacle to implementing them [14]. For example, the KDIGO 2022 guideline recommends treating patients with T2D, CKD, and an eGFR ≥30 mL/min/1.73 m² with metformin, whereas the ADA 2024 guideline does not include a specific recommendation for the use of metformin in adults with CKD and T2D [7,9]. Notably, PCPs have recognized that concise and clear CKD guidelines can be a positive facilitator for optimal CKD management [14]. In 2022, the ADA and the KDIGO Work Group collaborated to produce the ADA-KDIGO Consensus Report with the intention of harmonizing the two guidelines [15]. Specifically, the Consensus Report aligns the ADA and KDIGO recommendations in the areas of CKD screening, diagnosis, glycemic monitoring, lifestyle therapies, treatment goals, and drug management [15]. In addition, in an attempt to provide a clear direction for implementation of CKD care in patients with T2D, the Consensus Report helps to prevent guideline ‘favoritism.’

3.2. Accessibility of internet-based resources of guideline recommendations

The ADA Standards of Care and KDIGO Clinical Practice Guidelines are published online in article format (HTML and PDF documents) and are easily accessible through the ADA and KDIGO websites [44,45]. Both the PDF and HTML versions of the ADA and KDIGO guidelines have extensive content. For example, the KDIGO 2022 Clinical Practice Guideline for CKD in T2D management is a 128-page document, and the 2024 ADA Standards of Care is a 328-page document. In addition to the guideline for CKD in T2D management, KDIGO recently published an update to their guidelines for the Evaluation and Management of CKD (199 pages) [8], and separately published a Clinical Practice Guideline for the Management of Blood Pressure in patients with CKD, which is a 92-page document [46]. The length of these documents poses a potential limitation to their intended use, as they may not be easy for HCPs to navigate or convenient to use in busy clinical practice settings, especially in the limited time available to them during patient consultations. These barriers are especially pertinent within the time constraints of patient consultations, which is a reported limitation to the optimal management of CKD [13,14]. One study found that physicians perceived content-heavy CKD guidelines a hinderance to maximal clinical implementation [13]. Despite the intention of the collection of clinical practice guidelines to be an accessible resource for HCPs, the reality in many cases is different. Physicians have reported the dissemination of guidance from professional societies to practitioners as inadequate and a barrier to optimal management support to patients with CKD and T2D [14].

3.3. Availability of apps on mobile devices for easy access

To facilitate guideline usability in clinical practice settings, the ADA and KDIGO have developed free apps that provide access to their guidelines on mobile devices. The KDIGO mobile app is intended to help physicians and patients make treatment choices directly at the point of care in order to improve patient outcomes [47]. Similarly, the ADA Standards of Care app is intended for use by HCPs who treat and support patients with T2D in various settings [48]. For the most part, the ADA and KDIGO apps contain text copied from their guidelines as well as links to their respective websites. The KDIGO mobile app contains the latest KDIGO guidelines, with some interactivity, including a search function to look for specific topics or text [47]. The ADA Standards of Care app contains a ‘how to use’ guide that helps users maneuver around the app, as well as functions to navigate the guidelines, including a search function and table of contents [48]. The ADA Standards of Care app also contains interactive resources for HCPs to use in clinical practice settings, including treatment algorithms and clinical decision support-type tools, which are up to date with the latest guideline recommendations [48]. The ADA and KDIGO apps may help HCPs use and navigate the clinical guidelines more easily in practice settings (versus online formats). The interactive ADA resources may be beneficial to assist HCPs with point-of-care decision making in clinical practice settings. However, the ADA Standards of Care app does not show addendum updates that occur between the annual guideline updates, which compels HCPs to visit the main website for this information.

3.4. Versions of the guidelines specifically targeted at PCPs

Alongside the annual publication of their Standards of Care in Diabetes guideline, the ADA has published an abridged version of the 2024 guideline specifically intended for a PCP audience [49]. The abridged version contains only the evidence-based recommendations most pertinent to primary care presented in a user-friendly graphical format. Unlike the full document, the abridged version does not include references or background to the recommendations, such as information about the clinical studies behind the recommendations [49]. Despite this, a benefit of the abridged version of the guidelines (a 2-page PDF [for Chapter 11] versus the full 12-page PDF version) is that it allows PCPs to navigate the guidelines more easily. Without the additional context, PCPs may not be aware of the clinical evidence showing the benefits of guideline-recommended treatments in patients with CKD and T2D. Indeed, physicians have reported perceiving lack of evidence supporting guideline recommendations as a key barrier to implementation [13].

3.5. Additional resources for PCPs

The KDIGO website contains additional practice resources for HCPs, which are intended to complement the KDIGO guideline [50]. For example, the KDIGO resources page contains interactive visual guidelines, which are algorithms (a visual step-by-step treatment pathway to guide clinical decision making) for treatment based on the clinical guideline recommendations. The visual guideline for diabetes in CKD includes an overview algorithm for managing comorbid diabetes and CKD (lifestyle and drug interventions) as well as individual treatment algorithms (e.g. renin-aldosterone system [RAS] blockade, SGLT2 inhibitors, and GLP1 RAs) for CKD and T2D management [51]. Other visual resources available on the KDIGO website include ‘Top 10 takeways for Clinicans’ and infographics, which are quick-to-read, easily digestible educational resources intended to help time-challenged PCPs support patients with CKD and T2D or can be used to assist communication with patients about treatment [52]. Other available resources include webinars, presentations, videos, podcasts (which both KDIGO and ADA publish), and conference reports [50,53].

4. Implementation challenges

Despite attempts by guideline developers to increase guideline accessibility and ease of use by HCPs, challenges remain in the awareness and implementation of treatment recommendations in primary care. There are several reasons why these challenges persist. For example, primary care sits across multiple specialisms. As such, PCPs do not refer to only one specific treatment guideline, especially if a patient has multiple chronic diseases or comorbidities. Furthermore, PCPs find it difficult to keep abreast of guideline recommendations for CKD that seemingly change frequently [14]. Although the ADA-KDIGO Consensus report has provided harmonization in treatment guideline recommendations in CKD and T2D [15], some aspects are already out of date following publication of the 2024 KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD; furthermore, the ADA provide annual updates, whereas KDIGO updates individual disease-specific guidelines less frequently. In addition to the guideline updates, the ADA intermittently publishes addendums, as needed, when new important analyses/clinical data are available [54]. These addendums are published separately from the guidelines, rather than as an update to the current guideline, and therefore may be overlooked. A possible solution to keeping abreast of guideline updates may be the development of a ‘living guideline’ that is continually updated as new evidence emerges. In a living guideline, outdated content can be removed, and new content can be added without the need to wait for an updated guideline to be published, ensuring all content is consistently kept up to date.

Another barrier to PCPs implementing CKD guidelines is that PCPs may perceive the guidelines as rules but this is not the intention. Additionally, the guidelines aim to provide sufficient flexibility to facilitate appropriate and relevant patient-targeted care. A further barrier to implementation is that the recommendations typically direct the PCP on what to do, but do not provide a pathway on how to do it. For example, the KDIGO heat map [15] informs PCPs when and how often to treat (‘Treat 1,’ ‘Treat 2’) but does not provide the PCP with any additional context regarding what treatment, when, why, or how. Both the KDIGO 2024 (CKD focused) and KDIGO 2022 (CKD in diabetes focused) guidelines suggest that patients with CKD and T2D are treated with a comprehensive treatment strategy, which includes a foundation of lifestyle modification and self-management with pharmacologic management (e.g. first-line, second line, for additional risk factor control) layered on top [9]. The treatment guidelines do not inform PCPs how to prepare the patient or what to tell the patient when diagnosing CKD or when initiating treatment. The KDIGO heat map or similar tools and/or verbiage may be helpful when explaining CKD to a patient during a consultation [55]. Furthermore, the guidelines do not contain specific guidance on how to manage complex patients, such as patients with certain comorbidities (e.g. anemia due to CKD), and so may not be generalizable to all patients in real-world clinical practice. Additional resources informing PCPs how to translate guideline recommendations into practical guidance in real-world clinical settings are warranted. Figure 1 provides examples of a clinical care pathways according to each CKD stage based on the KDIGO heat map and notes the importance of adjusting treatment and monitoring frequency as appropriate based on patient need. Identification of strategies to resolve the challenges of appropriate content, adequate content, accessibility, and ease of use would greatly contribute to reducing the current clinical inertia in the optimal management of patients with CKD and T2D.

Figure 1. Sample CKD clinical care pathways for people with T2D based on UACR and eGFR. These are examples of pathways for implementation of the KDIGO heat map that is included in the ADA-KDIGO consensus report [15]. It is not intended to prescribe an exclusive course of management. Clinicians should consider the individual needs of their patients. Monitoring may include performing an eGFR, UACR, and/or additional tests according to patient needs (e.g. if they have other comorbidities) and/or monitoring for possible drug side effects (e.g. hyperkalemia should be monitored/managed in patients taking a RASi or ns-MRA). *Consider risk factors for CKD such as advancing age (especially >65 years), genetic factors, family history of T2D, family history of DKD (including age at diabetes onset between 5 and 15 years), family history of CKD, metabolic syndrome, obesity, insulin resistance, smoking, high blood pressure, racial and ethnic minority group, and use of nephrotoxic agents. ^†Risk of CKD progression. Patients are considered low risk if they have an eGFR ≥60 mL/min/1.73 m² and a UACR <30 mg/g and have no CKD/no other markers of kidney disease (e.g. hematuria, polycystic kidney disease, renovascular kidney disease, electrolyte abnormality etc.). ‡Author perspective: In primary care, patients with stage 1 or stage 2 CKD are typically treated with RASis (first-line) followed by SGLT2 inhibitors. The individual patient should be considered when choosing/initiating treatment. §Author perspective: Other reasons to refer to nephrology at all CKD stages include conditions such as gross hematuria or persistent microscopic hematuria, massive proteinuria, rapidly progressive decline in eGFR, and uncontrolled hypertension. ADA = American Diabetes Association; CKD = chronic kidney disease; DKD = diabetic kidney disease; eGFR = estimated glomerular filtration rate; KDIGO = Kidney Disease Improving Global Outcomes; ns-MRA = nonsteroidal mineralocorticoid receptor antagonist; RASi = renin angiotensin system inhibitor; SGLT2 = sodium glucose cotransporter-2; T2D = type 2 diabetes; UACR = urine albumin-to-creatinine ratio.

Figure 1. (continued).

5. How do we solve the implementation barrier?

There is a need to bridge the gap between guideline recommendations and their implementation in primary care. To achieve this, PCPs need suitable resources and tools to make it easier for them to do the right thing every time (i.e. make the right clinical decisions at the right time and communicate them in the right way with their patients) in their practice (Figure 1).

5.1. Utilizing diagnostic apps

Utilizing point-of-care tools, such as apps with clinical decision support algorithms, may assist physicians with detecting and determining CKD stage in practice. For example, the National Kidney Foundation has developed an eGFR calculator app, which allows HCPs to estimate kidney function using five separate eGFR equations [56], facilitating easier CKD diagnosis. Another useful app for PCPs is the MDCalc Medical Calculator app, which is intended to serve as a clinical decision support tool for HCPs [57]. This app contains over 275 calculators, spanning various medical specializations and conditions, to support HCPs in practice settings [57]. Relevant to CKD management, the app includes calculators for creatinine clearance, calculators for eGFR using different equations, and kidney failure risk calculators, which are accompanied by expert advice on matters such as when to use the calculators, pearls/pitfalls, and next steps. The app also provides HCPs with the evidence behind the tool upon which its use is based [57,58].

Another offering is the Medscape app, which provides a range of point-of-care tools, including medical calculators and a drug interaction checker [58]. Relevant to CKD, the app contains a ‘Decision Point’ feature that allows the user to select T2D, then under the ‘Management’ section one can select ‘Renal Complications’ from the menu. Here, the user can access educational videos led by subject matter experts on topics such as diagnosis and assessment, management, and prevention. The app also offers other useful information sources, such as prescribing information and reference articles for decision-making support [58]. The American Gastroenterology Association Non-Alcoholic Steatosis Hepatitis (NASH) app for screening and management of nonalcoholic fatty liver disease and NASH allows the input of patient measures to calculate the level of management the specific patient requires (low-, medium-, and high-risk management) and is a good example of an app that could be modified for CKD management [59]. UpToDate is a personal and institutional subscription-based electronic tool that provides current information and treatment recommendations for primary care and internal medicine, as well as for patients, across multiple specialties, including CKD and T2D [60]. The information may also be retrieved via a mobile app and is useful in supporting clinical decision making through algorithms and clinical images [61]. It is important to note, however, that the content included in some diagnostic apps may not have undergone a vigorous peer review process as publications in high impact factor academic journals.

5.2. Utilizing artificial intelligence to reduce administrative burden and assist PCPs with limited time

Using automated CKD decision support tools that are embedded into electronic health records (EHRs) may facilitate CKD management and guideline implementation in clinical practice settings. For example, EHR alerts can be used to remind PCPs when to perform eGFR and UACR tests for CKD. Such alerts can be aligned with the testing frequency recommended in the guidelines (at T2D diagnosis and yearly thereafter in patients with T2D [15]) to facilitate guideline implementation. In a group-randomized study involving 21 primary care practices across 13 US states, adoption of EHR-based reminders for albuminuria testing contributed to an increase in the number of patients either at risk for or with CKD who received albuminuria testing [62]. EHRs can also be helpful for patients by facilitating communication between PCPs and their patients regarding topics such as laboratory results and a tool for checking a patient’s adherence to CKD monitoring cadence in lieu of additional (possibly unnecessary) clinic visits [63]. Another mechanism to support the PCP-patient decision-making process is utilizing artificial intelligence (AI) embedded in the EHR to identify patients at risk for CKD and to predict their rate of kidney function decline. Using an electronic CKD phenotype, AI can analyze available laboratory data in the EHR to detect CKD with high sensitivity, specificity, and diagnostic accuracy [64] and may be beneficial to facilitate CKD detection and guideline implementation. Embedding an electronic clinical decision support system within the EHR has been shown to increase PCPs’ awareness of CKD [65]. Such studies utilizing AI in kidney disease are at a preliminary stage and limited by small sample sizes. Larger-scale studies are warranted to determine the potential of AI in facilitating CKD detection and management.

5.3. Create visual and video/digital resources as practice tools for PCPs to utilize in practice

PCPs may perceive CKD guidelines as ‘lacking’ or including inadequate educational resources, such as easily applied algorithms, to inform them on how to implement guideline recommendations in their practices [14]. Provision of up-to-date visual resources that aid PCPs with clinical decision making and patient communication in practice is needed. In response, we have created a visual resource containing a hypothetical patient profile based on a real-world example of a hypothetical patient (Figure 2). In real-world scenarios, patients are part of a larger community in contrast to patients included in large randomized clinical trials (results from which are used to inform the clinical guideline recommendations). The hypothetical patient profile shown in Figure 2 is intended to provide a real-world example of the type of patient who would receive guideline-recommended therapies, to assist PCPs with clinical decision making. Additionally, as introduced earlier in our review, we have developed a simple clinical care pathway based on CKD stage, according to the KDIGO heat map (ADA/KDIGO Consensus report) [15]. The sample pathways are intended to translate the current guideline recommendations into clear, at-a-glance, and actionable treatment advice (Figure 1) that can also be used as a tool to facilitate discussions with patients regarding their CKD diagnosis. Patient engagement is also important – resources that aid patient engagement, improve patient knowledge about CKD, and facilitate shared decision making with the patient in practice settings are also needed.

Figure 2. Hypothetical patient profile of an adult patient with CKD associated with T2D. The hypothetical patient profile presented here is fictional (not a real patient case). The content in this figure was provided by the authors and represents the opinions of the authors. The profile is intended to represent a clinical profile of an adult patient with CKD associated with T2D. ARB = angiotensin receptor blocker; BMI = BMI + Body Mass Index; BP = blood pressure; BUN = blood urea nitrogen; CKD = chronic kidney disease; CV = cardiovascular; eGFR = estimated glomerular filtration rate; HbA1C = hemoglobin A1c; K+ = potassium; KDIGO = Kidney Disease Improving Global Outcomes; LDL = low-density lipoprotein; Na+ = sodium; T2D = type 2 diabetes; UACR = urine albumin-to-creatinine ratio.

6. Conclusion

Many PCPs do not routinely follow treatment guideline recommendations for CKD and T2D. The consequence is that many patients with these conditions may remain largely undetected in primary care and may not receive appropriate kidney and cardiovascular protective therapies. A key barrier to implementing guideline recommendations in primary care is a lack of awareness and guidance on how PCPs can effectively implement the guidelines in their real-world practices. Guideline developers have attempted to support HCPs with guideline implementation by providing additional tools that help translate the formal guideline recommendations into easier-to-digest practical guidelines, such as mobile apps; PCPs need to utilize these resources. However, ongoing low implementation of guidelines in primary care highlights the need for additional resources and tools for PCPs, such as clinical decision support tools in the form of apps, AI, and visual/digital resources, as well as implementation strategies that will support PCPs with clinical decision making in CKD and T2D.

Declaration of financial/other relationships

EEW is on the Speakers’ Bureau for Abbott Diabetes, Bayer, Boehringer Ingelheim, Eli Lilly, GSK, and Sanofi; is on the Advisory Boards of Abbott Diabetes, Bayer, Boehringer Ingelheim, Eli Lilly, Medtronic, and Sanofi; and is a consultant for Abbott Diabetes, Bayer, Boehringer Ingelheim, and Eli Lilly. SBN has received research support from NIH/NCATS, NIH/NIMHD, CDC, Travere, and Bayer; is on the Editorial Board of American Journal of Kidney Disease; is an Associate Editor of Journal of the American Society of Nephrology; is on the Advisory Board/Steering Committee of Boehringer Ingelheim/Lilly Pharmaceuticals, AstraZeneca, Bayer, NovoNordisk, and Janssen Pharmaceutical; is a consultant/National Leader for Bayer-ND-CKD; and has received honoraria for 2021–2022, 2023 Hypertension Highlights, ADA, 2023 ASN nephSAP. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Peer reviewers on this manuscript have received an honorarium from IPGM for their review work. A reviewer on this manuscript has disclosed being involved in the KDIGO 2020 and 2022 Diabetes guidelines as the methods lead. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Author contributions

Eugene E. Wright and Susanne B. Nicholas contributed to the writing and reviewing of each draft and reviewing and approving the final draft for submission and publication.

Acknowledgments

Medical writing support was provided by Charlotte Maddocks of Alligent, part of Envision Pharma Group, and this support was funded by Bayer Corporation. Envision Pharma Group’s services complied with international guidelines for Good Publication Practice.

Additional information

Funding

Bayer Corporation funded the processing charges for this article. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.