Missing opportunity for nephroprotective therapy in non-dialysis CKD patients under stable nephrology care

Introduction.Awareness of implementation of guideline-directed nephroprotective therapy (GDNT) is an essential preliminary step to optimize implementation of nephroprotective strategies in non-dialysis CKD (ND-CKD).However, no updated information on this issue is available in the setting of nephrology clinics. Methods.In this multicenter prospective study we collected data of 4,523 patients with ND-CKD, either stage 3-5 or 1-2 with ACR>30 mg/g, followed in 30 Italian nephrology clinics in two visits with a 6-month interval between May/2024-May/2025 to evaluate current phenotypes of patients under tertiary nephrology care, and management of the two major modifiable determinants of renal risk, hypertension and albumin-creatinine ratio (ACR), including therapeutic inertia. Results.The cohort was characterized by a severe cardiorenal risk profile: men 65%, age 7114y, diabetes 40%, cardiovascular disease 40%, eGFR 3419 mL/min/1.73m 2 , ACR 70 mg/g .At month-6 visit, in patients with and without diabetes, home and office blood pressure (OBP) were above target in about 70% patients, with high prevalence of sustained (62%) and resistant (23%) hypertension.Among patients with uncontrolled OBP, 43% and 33% of nondiabetic and diabetic patients were prescribed 2 BP lowering drugs.ACR>30 mg/g persisted in 61% of nondiabetic and 64% of diabetic patients with frequent occurrence of therapeutic inertia for antialbuminuric agents at month-6: 85% for RAS inhibitors, 90% for gliflozins, and, among patients with diabetes, 92% for GLP1-RA and 96% for finerenone.Conclusions.The large majority of patients with ND-CKD currently followed in Italian renal clinics is characterized by a severe risk profile that is paradoxically associated with remarkable therapeutic inertia for traditional and innovative GDNT.