Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA.
Department of Medicine, Uniformed Services University, Bethesda, MD, USA.
Nephrol Dial Transplant. 2023 Feb 28;38(3):532-541. doi: 10.1093/ndt/gfac283.
For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.
多年来首次出现了一些指南指导的药物治疗方法，这些方法为慢性肾脏病（CKD）和 2 型糖尿病患者提供了实质性的心肾益处、提高了生活质量和延长了寿命。这些治疗选择包括钠-葡萄糖共转运蛋白-2 抑制剂、非甾体类盐皮质激素受体拮抗剂和胰高血糖素样肽-1 受体激动剂。然而，尽管有多项临床试验提供了确凿的证据，但这些基于证据的治疗方法在常规临床实践中的应用进展缓慢，让人想起血管紧张素转换酶抑制剂和血管紧张素 II 受体阻滞剂使用的历史演变。这些循证治疗方法的实施延迟凸显了优化 CKD 护理所面临的许多挑战，包括：（i）临床惯性；（ii）CKD 意识低下；（iii）患者和提供者的肾脏疾病教育不足；（iv）缺乏患者和社区参与；（v）多病共存和多种药物治疗；（vi）初级保健环境中的挑战；（vii）CKD 护理碎片化；（viii）服务不足人群中的差异；（ix）缺乏关注健康公平的公共政策；以及（x）药品价格高昂。通过使用慢性护理模型框架，采用多方面的方法，包括患者和提供者教育、患者自我管理计划、共同决策、电子临床决策支持工具、质量改进举措、明确的实践指南、多学科和协作护理、提供者责任以及强大的健康信息技术，可以缓解这些优化心肾结局的障碍。全球肾脏社区有责任通过解决患者、社区、提供者、医疗保健系统和政策层面的障碍，从多维角度看待 CKD 护理。
