LAUSR

In their article, Navaneethan and colleagues (1) present a synopsis of a 2022 clinical practice guideline update for diabetes management in chronic kidney disease (CKD) (1). They report changes to the Kidney Disease: Improving Global Outcomes (KDIGO) 2020 guidelines in 2 areas, comprehensive care and glucose-lowering therapies in patients with type 2 diabetes and CKD. The KDIGO 2022 guidelines build on high-quality evidence that supports newer medications to prevent CKD progression and CKDassociated complications (2). These updated recommendations are exciting for their potential to change the natural history of CKD and diabetes, but their effect could be highly limited by barriers at multiple levels—patient, clinician, and health system. The KDIGO 2022 guideline speaks primarily to the broader indications and safety of 3 drug classes for patients with diabetes and CKD: sodium–glucose cotransporter-2 (SGLT2) inhibitors, nonsteroidal mineralocorticoid receptor antagonists (MRAs), and glucagon-like peptide-1 receptor agonists (GLP-1 RAs). Recognizing the cardiorenal protection of SGLT2 inhibitors, the guideline now recommends them for all people with diabetes and CKD regardless of glycemic level. They can also be prescribed for patients with diabetes and CKD with an estimated glomerular filtration rate (eGFR) of 20 mL/min/1.73 m or higher (vs. eGFR >30 mL/min/1.73 m in the 2020 guideline). Furthermore, SGLT2 inhibitor treatment can be continued up to kidney replacement therapy if a patient is already tolerating the medication. Nonsteroidal MRAs are recommended tomaximize renin–angiotensin system inhibition for individuals receiving the maximal tolerated dosages of angiotensinconverting enzyme inhibitors and angiotensin II receptor blockers who still have albuminuria (>30 mg/g). Finally, GLP-1 RAs remain second-line therapy for glucose lowering in type 2 diabetes and CKD, but an additional practice point suggests the use of GLP-1 RAs in patients with obesity (and type 2 diabetes and CKD) to promote intentional weight loss (1). These new recommendations build on a bedrock of unchanged recommendations for lifestyle interventions and self-management (2). The KDIGO 2022 guidelines have the potential to change disease trajectories for patients with CKD and diabetes. However, major barriers to real-world implementation of these drugs exist at multiple levels (3). For these newer medications to fulfill their promise of reducing CKD progression and cardiovascular complications, they have to reach the right patients at the right time. Unfortunately, patient uptake of these medications has been slow and uneven. Although SGLT2 inhibitors were approved nearly a decade ago, usage is still low. In 2020, fewer than 8% of older adults with CKD and diabetes were receiving SGLT2 inhibitors regardless of CKD stage, race, or insurance status (4). Patients with CKD, cardiovascular disease, and prior hypoglycemia were less likely to use SGLT2 inhibitors, despite clear evidence of benefit in these patients (5). Patients with social advantages—younger patients, nonBlack patients, and those with commercial insurance— were more likely to receive SGLT2 inhibitors (6). Based on commercial claims, it is estimated that fewer than 14% of people with diabetes and cardiovascular disease received a GLP-1 RA between 2018 and 2020 (7). Data for nonsteroidal MRA use are not yet available because U.S. Food and Drug Administration approval occurred in 2021. Although past clinical trials have been criticized for their lack of inclusivity of older adults with multimorbidity, KDIGO's 2022 guideline is based on large-scale trials that included various participants with multimorbidity and were more reflective of the patients we treat in practice. For example, FIDELIO-DKD (Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease) and FIGARO-DKD (Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease) included patients with a greater range of eGFRs and more severe albuminuria than are typically included in clinical trials. The trials also included older patients, women, and racial and ethnic minoritized patients, although they were not fully representative for sex and race (8). The recommendations give parameters for starting and stopping medication treatments based on clinical values—eGFR, hemoglobin A1c, potassium, and albuminuria— which is an improvement. However, use of these medications is still limited by the lack of data on long-term use of any of these newer medications. At the clinician level, there can be slow diffusion of medical information. Patients may also not receive guidelinerecommended treatments because of concerns about adverse events from polypharmacy, high copayments for these drugs, lack of access because of formulary restrictions, and clinician uncertainty about expected benefit. Furthermore, primary care clinicians may find it challenging to integrate these recommendations alongside the multitude of recommendations for preventive care and other chronic diseases (9). More than 40% of patients with diabetes have CKD; most of these patients are cared for by primary care clinicians (4). Although it is helpful that KDIGO and the American Diabetes Association have partnered for these guidelines, many patients with diabetes and CKD have other comorbidities, like cardiovascular disease or heart failure, whose care may dictate a different medication algorithm. Collaborations with professional organizations, like the American Heart Association or the American Geriatrics Society, would help to create a more unified and streamlined set of recommendations befitting patients with diabetes and CKD who have multiple other chronic conditions. At a societal level, structural inequalities will impede adoption of this new guideline. The 2022 and 2020 KDIGO guidelines focus only on clinicianand health system–level