Bridging the Gap: Accelerating Slow Uptake of Novel CKD Therapies with Structured Optimization Clinics

Background: Recent advances in chronic kidney disease (CKD) treatment have introduced several promising therapies, such as sodium-glucose co-transporter 2 (SGLT2) inhibitors and non-steroidal mineralocorticoid receptor antagonists like finerenone. Despite strong evidence and NICE guidelines, real-world uptake remains slow due to practical challenges, evolving guidance, and healthcare system limitations. This study evaluated gaps between evidence-based recommendations and prescribing practices in general nephrology clinics. Methods: A retrospective analysis of 308 patients attending nine general nephrology clinics at a tertiary center (Sheffield Kidney Institute) over three weeks was conducted. Eligibility for initiation or up-titration of renin-angiotensin-aldosterone system (RAAS) inhibitors, SGLT2 inhibitors (dapagliflozin and empagliflozin), and finerenone was assessed using predefined NICE criteria. We documented whether medication optimization was considered and recorded reasons for non-initiation. Results: Of 308 patients, 42% (n=129) were not receiving optimal CKD pharmacotherapy. Ten were eligible for RAAS inhibitor initiation, and 84 for up-titration. Twenty-seven met criteria for empagliflozin (18 with eGFR 20–45 ml/min/1.73m2; 9 with eGFR >45 with uACR >22.6 mg/mmol or T2DM), and seven for finerenone. Optimization was considered in 68% of cases; in 32%, it was not documented. Reasons for non-initiation included: deferral to primary care (22%), awaiting pathways (18%), clinician hesitation (14%), side effects (13%), contraindications (13%), no follow-up (7%), frailty (3%), patient hesitation (2%), and other/unspecified (8%). Conclusion: There is a clear disconnect between guideline-driven CKD management and clinical practice, exacerbated by the complexities of RAAS inhibitor titration, uncertainty regarding the necessity of maximum dosing before starting newer agents such as SGLT2 inhibitors or finerenone, and frequent follow-up requirements. To address these barriers, we established dedicated RAAS titration services aimed at rapidly achieving optimal dosing to facilitate earlier initiation of newer therapies. Further solutions include structured CKD optimization clinics, streamlined clinical pathways, improved coordination between primary and secondary care, and focused clinician education to enhance prescribing confidence and patient outcomes.