Guideline-Directed Medical Therapy in Patients with CKD: Care Trends, Disparities, and Outcomes

Background Guideline-directed medical therapy (GDMT)—including RAAS inhibitors, SGLT2 inhibitors, nonsteroidal MRAs, and GLP-1 receptor agonists—helps slow CKD progression and reduces cardiovascular risk, yet its use varies across sociodemographic groups. Methods We conducted a retrospective study using 2016–2023 Centers for Medicare & Medicaid Services claims data from Medicare Part D beneficiaries with CKD (excluding those on dialysis) to examine trends in GDMT use. Outcomes assessed included progression to end stage kidney disease (ESKD), hospitalizations, re-hospitalizations, emergency department utilization, and mortality, stratified by race/ethnicity and socioeconomic status. Results Among 9.6 million patients, RAAS inhibitor use was stable between 2016 and 2023, while SGLT2 inhibitor and GLP-1 receptor agonist use rose; nonsteroidal MRA uptake remained low. GDMT use was highest for patients with diabetes and for Asian/Pacific Islander and Hispanic patients. Use was lowest among non-Hispanic White and Black patients (Figure). GDMT was associated with favorable clinical outcomes; the adjusted odds ratios (95% confidence intervals) were 0.65 (0.64-0.65) for mortality, 0.86 (0.85-0.86) for hospitalization, 0.68 (0.67-0.69) for ESKD, 0.83 (0.82-0.83) for hospital readmission, and 0.88 (0.88-0.89) for emergency room visits. GDMT use combined with nephrology care was associated with better outcomes; the odds ratio for one year mortality was 0.56 (0.55-0.56) for patients with GDMT and nephrology care in the past year versus neither. The association of GDMT with most favorable outcomes was larger for Black and Hispanic patients relative to non-Hispanic White patients. Conclusion GDMT use in CKD is increasing, largely driven by SGLT2 inhibitors. In this cohort of patients with Medicare, combined GDMT use with nephrology care was associated with the most favorable outcomes across race/ethnicity groups.