Slowing CKD, Adherence to Care Guidelines Need to Improve, Study Says

February 25, 2021
Larry Hanover

Adherence to guidelines for slowing chronic kidney disease is low, with substantial variation among the United States and other countries.

Despite the introduction of guidelines 9 years ago for slowing the progression of chronic kidney disease (CKD), a review of real-world data shows that adherence is low and the recommendations are inconsistently applied among the United States and other countries.

The Kidney Disease: Improving Global Outcomes guidelines for treating CKD were adopted in 2012. Key recommendations include targets for blood pressure (BP), using renin-angiotensin-aldosterone system inhibitors (RAASi), and advising patients not undergoing dialysis to cut back on salt and protein.

However, a review of real-world data, published in Kidney International Reports, found that adherence to the guidelines was low in the United States, Brazil, France, and Germany and that there was considerable variation among the countries.

CKD affects 11% to 13% of the population worldwide. Although awareness of the disease and the corresponding risks of kidney failure, cardiovascular disease, and death has risen, the authors said, advances in preventing kidney failure have been slow and the need for kidney replacements is rising in some high-income nations, prompting the need for better understanding of adherence to guidelines.

The investigators reviewed data from the Chronic Kidney Disease Outcomes and Practice Patterns Study database, a prospective cohort study of patients with moderate and advanced CKD in the 4 countries. The data represented 7204 patents from 118 clinics, including 1511 patients from 29 clinics in the United States.

The study showed adherence in the United States was consistently low in the key categories. Only 27% of patients were receiving any kind of dietary advice to slow CKD progression, and only 38% were at or below the systolic BP target of 130/80 mm Hg. In addition, even though RAASi are considered a first-line treatment for CKD, the United States ranked lowest among the 4 countries, with only 52% of patients receiving the drugs.

As far as treating patients with CKD and comorbid diabetes, whose blood sugar levels (hemoglobin A1c of about 7%) represent a fourth target, the United States fared better than in the other categories. There was 56% adherence on keeping track of hemoglobin A1C levels.

Overall, BP control (≤140/90 mm Hg) ranged from 49% in France to 76% in Brazil, and Brazil (52%) was the only country with more than 40% of patients with blood pressure ≤130/80 mm Hg. Prescription of RAASi ranged from 52% in the United States to 81% in Germany.

Patients with CKD who did not have diabetes had a poor record of hitting all 3 targets, ranging from 10% in the United States to 32% in Brazil. Diabetes, as expected, was found to be a leading cause of CKD and a major comorbidity. For patients with diabetes who were measured on meeting the 3 key targets, along with glycemic control, the range for meeting all 4 targets ranged from 6% in the United States to 11% in Brazil.

The study also noted low adherence in measurement of albuminuria or proteinuria. The conditions were routinely measured in fewer than half of patients in the United States, Brazil, and Germany, with proteinuria measured more often than albuminuria in all countries. Results also showed that dipstick proteinuria was often used alone despite potential inaccuracy.

The authors further noted surprise to see that measuring the albumin-to-creatinine ratio did not seem to be standard practice.

One positive result was that 12% or less of the populations in the 4 countries were current smokers, making this just about the only recommended lifestyle change with demonstrated adherence. Patients reported getting advice on low sodium intake, but not for protein, potassium, or phosphorus intake. A majority had no access to expert dietary advice at all.

“Adherence to recommendations to slow CKD progression is low in typical practice settings,” the authors concluded, “and substantial variation among countries for some indicates opportunities for improvement.”


Stengel B, Muenz D, Tu C, et al. Adherence to the kidney disease: improving global outcomes CKD guideline in nephrology practice across countries. Kidney Int Rep.2021;6(2):437-448. doi:10.1016/j.ekir.2020.11.039