Abstract
Diabetic kidney disease (DKD) affects 30–40% of all patients with diabetes and contributes significantly to the cardiovascular burden of chronic kidney disease (CKD). Despite the availability of evidence-based medications like finerenone and simple screening tests such as Urinary Albumin-to-Creatinine Ratio (UACR), more resources are still needed to care for DKD patients. Physician Associates (PAs) play a crucial role in the multidisciplinary team responsible for DKD diagnosis, monitoring, and management. A nonsteroidal mineralocorticoid receptor antagonist, namely finerenone, was approved by the FDA in adults with CKD associated with type 2 diabetes to reduce the risk of renal and cardiovascular outcomes. Finerenone is considered among the pillars of care for DKD, furthermore, the addition of finerenone in combination with renin-angiotensin system inhibitors and/or other renal protective medications may offer additional benefits. Primary care providers prescribe finerenone less frequently than specialized care providers, indicating a need to empower physician associates in medication prescription and other renal protection strategies. As part of a multidisciplinary team, physician associates can play an important role in evaluating risk factors that contribute to heart disease and metabolic health. They can also monitor not only kidney function by ordering tests, such as serum creatinine and urinary albumin-to-creatinine ratio every 3–12 months, but also serum potassium levels. Additionally, physician associates can encourage patients to take responsibility for their health by regularly monitoring their blood pressure, blood glucose levels, and body weight. With early detection and management, kidney failure and cardiovascular events may be preventable. Specialized physician associates also play a significant role in the comprehensive care of DKD patients, especially in the later stages. DKD care can be hindered by numerous factors such as lack of patient engagement during counseling, cost disparities, and a complex referral system that requires multidisciplinary guidelines to improve professional communication. It is necessary to re-envision the physician associates’ role in primary care and empower them in goal-directed therapies.
Graphical abstract
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
According to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline, Chronic Kidney Disease (CKD) is a medical condition in which the presence of a structural or functional kidney abnormality persists for three months or longer. Individuals with CKD experience a significantly higher burden of cardiovascular disease (CVD) and all-cause mortality [1]. According to a recent study that included Canada and ten European countries, the prevalence of CKD was 10%. A separate report estimated that 14% of the adult population in the United States had CKD, but only 1 in 10 Americans with CKD were aware of their condition [2]. Furthermore, approximately 30–40% of patients with all types of diabetes mellitus (DM) were estimated to also have diabetic kidney disease (DKD) [2]. However, patients with Type 1 DM are typically younger at DKD diagnosis and have fewer comorbidities, such as insulin resistance and obesity, which are commonly associated with Type 2 DM (T2DM) [3].
Chronic kidney disease is staged based on the underlying cause, estimated glomerular filtration rate (eGFR) category (G1–G5), and albuminuria category (A1–A3). It is important to provide a complete description of the CKD stage rather than just the eGFR category [4]. Usually, serum creatinine, as the primary filtration marker, is used for estimating GFR. The CKD Epidemiology Collaboration has created a new creatinine-based eGFR equation that does not require adjustments for race as a response to the controversy of using race coefficients in clinical algorithms [5]. Urinary albumin-to-creatinine ratio (UACR) is recommended to measure albuminuria, which is more accurate than measuring urine albumin concentration alone and can be taken from a single random urine sample [6]. Both eGFR and urinary albumin-to-creatinine ratio can predict increased CVD risk [7]. Regardless of the diabetic condition, the association between impaired eGFR, albuminuria, and negative outcomes remains consistent [8]. Chronic kidney disease risk stages with reference to eGFR and albuminuria, according to KDIGO guidelines, are shown in Fig. 1. Urinary albumin-to-creatinine ratio and eGFR should be measured at least once per year in patients with low and moderate CKD risk, which include G1A1, G2A1 (green) and G1A2, G2A2, G3aA1 (yellow) [9].
Prior to the first clinical trial testing the use of renin-angiotensin system inhibitors (RASi) in 1993, there were no treatments available to stop the progression of DKD beyond glycemic and blood pressure control [10]. Substantial evidence supports that sodium-glucose cotransporter 2 inhibitors (SGLT-2i) and nonsteroidal mineralocorticoid receptor antagonists (nsMRAs) slow DKD progression when used alongside renin-angiotensin system inhibitors in T2DM patients. Moreover, the secondary outcomes of clinical trials involving glucagon-like peptide-1 receptor agonists (GLP-1RAs) have shown renal protective benefits besides their glycemic control effect [11]. However, primary studies investigating the renal benefit of Glucagon-Like Peptide-1 Receptor Agonists are ongoing and will determine the usefulness of adding a Glucagon-Like Peptide-1 Receptor Agonist to the renal protecting pillars [12]. Finerenone is a nonsteroidal mineralocorticoid receptor antagonist that has shown strong evidence in lowering the risk of CVD and DKD among a wide spectrum of patients with albuminuria [13]. The latest KDIGO guidelines have adopted a holistic approach to DKD therapies and recommended optimizing renin-angiotensin system inhibitors to the maximum toleraated dose in patients with (G1–G4, A2–A3; Fig. 1) and starting sodium-glucose cotransporter 2 inhibitors for treating patients with T2DM and eGFR ≥ 20 ml/min per 1.73 m2. The guidelines have also suggested starting finerenone for adults with T2DM and eGFR > 25 ml/min per 1.73 m2 who have (A2–A3; Fig. 1) despite the maximum tolerated dose of renin-angiotensin system inhibitors [14]. Primary care is significantly composed of physician associates (PAs) who play a vital role in diagnosing, monitoring, and managing CKD, DM, and CVD. By working collaboratively with other healthcare professionals, physician associates can take the initiative in slowing the progression of DKD, lowering mortality rates, and reducing healthcare costs [15, 16].
Finerenone benefits in DKD
Two complementary phase III trials, FIDELIO-DKD and FIGARO-DKD, tested the efficacy and safety of finerenone and shared similar designs and endpoints. In FIDELIO-DKD, patients with stage 3–4 CKD and T2DM, who were on maximum tolerated renin-angiotensin system inhibitors, had a significantly reduced risk of the primary kidney outcomes and the key secondary cardiovascular composite outcomes when receiving finerenone [17]. Meanwhile, FIGARO-DKD showed that finerenone significantly reduced the primary cardiovascular composite outcome risk in patients with stage 2–4 CKD and moderately increased albuminuria, or in stage 1–2 CKD with severely increased albuminuria (Table 1) [18]. The FIDELITY pooled analysis, including 13,026 participants with CKD and T2DM from the FIDELIO-DKD and FIGARO-DKD trials combined, showed that finerenone reduced cardiovascular outcomes by 14% and kidney outcomes by 23% compared to placebo (Table 1) [13].
Finerenone was first approved by the U.S. Food and Drug Administration (FDA) on July 9th, 2021, to reduce the risk of sustained eGFR decline, end-stage kidney disease (ESKD), cardiovascular death, nonfatal myocardial infarction, and hospitalization for heart failure in adults with CKD associated with T2DM [19, 20]. The National Institute for Health and Care Excellence (NICE) in the United Kingdom recommends finerenone for patients with albuminuria and eGFR ≥ 25 ml/min/1.73 m2 as an add-on to optimized standard care of stage 3 and 4 DKD, which includes the highest tolerated licensed doses of renin-angiotensin system inhibitors and sodium-glucose cotransporter 2 inhibitors [21]. Many healthcare providers mistakenly believe that novel glucose-lowering drugs, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists, are the adequate or even ultimate solution for patients with T2DM and CKD. However, this is not accurate, considering the additional benefits of different DKD guideline-directed medical therapies achieved by addressing separate pathways [22]. The benefits of nonsteroidal mineralocorticoid receptor antagonists remain intact in patients with CKD and T2DM, despite the use of other protective medications, such as sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor agonists [23, 24].
The large clinical trials of sodium-glucose cotransporter 2 inhibitors in DKD were started before finerenone FDA approval and included a small subgroup who were using steroidal mineralocorticoid receptor antagonists [25,26,27]. However, secondary analyses of randomized trials involving finerenone showed the additional benefits of introducing finerenone on top of sodium-glucose cotransporter 2 inhibitors About 7% of the FIDELITY population had concomitant use of sodium-glucose cotransporter 2 inhibitors (Table 1), and the hazard ratios for the composite endpoint of kidney disease were 0.80 (95% CI 0.69–0.92) without sodium-glucose cotransporter 2 inhibitors and 0.42 (95% CI 0.16–1.08) with sodium-glucose cotransporter 2 inhibitors [23]. The currently ongoing CONFIDENCE trial (NCT05254002) will evaluate the effectiveness of combining finerenone with empagliflozin in individuals with both CKD and T2DM, using a urinary albumin-to-creatinine ratio endpoint. The trial recruited patients with CKD stage 2–3, an eGFR of 30–90 mL/min/1.73 m2, a urinary albumin-to-creatinine ratio ≥ 300– < 5000 mg/g, and on maximum tolerated dose of renin-angiotensin system inhibitors. It is expected to end in mid-2024 [28].
Role of physician associates in maximizing the benefits gained from finerenone
The care of CKD patients involves various tasks that can be performed by physician associates. These tasks include assessing risk factors related to heart disease and metabolic health, monitoring kidney function through tests like serum creatinine and urinary albumin-to-creatinine ratio every 3–12 months and serum potassium, and encouraging patients to take charge of their own health through self-monitoring of blood pressure, blood glucose levels, and body weight. Furthermore, during regular check-ups, treatment targets and side effects of medications like statins, renin-angiotensin system inhibitors, sodium-glucose cotransporter 2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists, and Glucagon-Like Peptide-1 Receptor Agonists are reviewed, and patients are given advice on healthy eating, exercise, and self-monitoring [29]. If non-severe hyperkalemia occurs with the prescribed medications, new potassium binders are available for continued therapy [30, 31]. Cooperation between physicians, physician associates, and other healthcare professionals, aided by technology, will enable personalized management and self-care for CKD patients. Practitioners in team-based care should use an information system with decision support to define care processes and streamline workflow for structured care (see Fig. 2) [29]. In a recent cluster randomized trial, practice facilitation programs by multidisciplinary care for primary care improved CKD and CVD outcomes [32]. Reorganizing primary care to include multidisciplinary teams can emphasize the crucial roles that physician associates are currently playing in the CKD care process and prepare the health system at the state and national level to address any potential physician shortage. It is anticipated that the United States may experience a scarcity of 37,800 to 124,000 physicians by 2034, with primary and specialty care being mainly affected [33].
However, not all primary care offices have the bandwidth to function as a multidisciplinary team. Geographic location, financial and workforce resources, reimbursement practices, and patient complexity can affect the availability and functionality of multidisciplinary teams [34]. A single institution prescription pattern showed that specialists prescribed finerenone (66%) more frequently than Primary Care Providers (PCPs). Among specialists that prescribed finerenone, 26% were in cardiology, 30% in nephrology, and 10% in endocrinology [35].
Early CKD journey
If CKD is identified early and managed properly by non-nephrology physician associates, it may delay disease progression and avoid dialysis or transplant. In a performance improvement project, non-nephrology physician associates were provided with the Kidneys in a Box (KIB) tool. This tool focused on six modifiable factors in DKD, which are derived from the National Institutes of Health’s National Kidney Disease Education Program (NIH/ NKDEP) and includes statin use, hemoglobin A1c (HbA1c) measured within the last 6 months, urinary albumin-to-creatinine ratio measured within the last year, CKD stage, a yellow caution over-the-counter (OTC) medication list to decrease iatrogenic kidney injury, and smoking cessation [36]. Physician associates completed the program within the first 24 months, and full data were available for 213 physician associates, resulting in statistically significant behavioral changes in five of the six modifiable risk factors [36].
Adjusting diabetic medications, targeting lower HbA1c levels, and detecting the stage of CKD are crucial tasks for physician associates. Measuring both eGFR and urinary albumin-to-creatinine ratio is necessary to accurately determine CKD stage. In patients with DM and urinary albumin-to-creatinine ratio levels exceeding 30 mg/g, even those who are normotensive, renin-angiotensin system inhibitors are recommended to prevent or delay the progression of DKD [37]. After reaching the maximum tolerated dose of renin-angiotensin system inhibitors, finerenone initiation is recommended if albuminuria persists [38]. Finerenone is available in 10 mg and 20 mg film-coated tablets, and the initial dose depends on the patient's eGFR. For patients with normal or slightly reduced eGFR (≥ 60 mL/min/1.73 m2), the recommended starting dose is 20 mg once daily. However, for those with severe renal impairment (25–59 mL/min/1.73 m2), the starting dose is 10 mg once a day. Patients with an eGFR below 25 mL/min/1.73 m2 or serum potassium concentration above 5.0 mEq/L should not initiate finerenone (Fig. 3) [39].
Late CKD journey
Patients are diagnosed with very high CKD risk if they have G3aA3, G3bA2, G3bA3, G4A1, G4A2, G4A3, G5A1, G5A2, or G5A3 (Fig. 1) [4]. Typically, when the prevention strategies in primary care fail to halt CKD progression, patients should be referred to specialized care and renal clinics [40]. However, CKD is often not identified until late, resulting in nephrologists being the first to diagnose it. This commonly occurs when a hospitalized patient with an acute kidney injury needs a nephrology consultation, during which the nephrologist notes that the patient has had CKD for years that was never formally documented or discussed. In nephrology, historically, physician associates would only manage dialysis patients, but now they are responsible for managing complex patients in various settings such as hospitals, ICUs, offices, and dialysis units [41]. Physician associates play an important role in the team effort to aggressively treat CKD and its related conditions, such as anemia, bone and mineral disorders, electrolyte imbalances, and fluid management [42]. Furthermore, patients with late DKD stages are often prescribed multiple medications, including renin-angiotensin system inhibitors, sodium-glucose cotransporter 2 inhibitors, and finerenone, which can cause fluctuations in serum potassium levels if dosages are adjusted or stopped [39]. When starting finerenone or increasing the dosage, monitoring serum potassium and eGFR levels for at least 4 weeks is crucial. If hyperkalemia occurs, withholding or down-titrating medications that increase serum potassium levels and taking oral potassium binders can help reduce serum potassium levels and allow for the safe use of finerenone (Fig. 3) [43].
The importance of continuity of care in CKD
Ensuring continuity of care is crucial for high-quality healthcare, which includes information continuity and management continuity. Information continuity involves the availability and use of data from past events during current patient encounters [44]. Management continuity ensures the coherent delivery of care between different healthcare providers and institutions [44]. Higher continuity of care was associated with a lower risk of ESKD among patients with diabetic renal complications [45].
Barriers to optimum care for CKD patients
Insufficient patient engagement during the counseling process
The majority of patients with CKD are asymptomatic, resulting in challenges in comprehending the impact CKD has on their overall health. Chronic kidney disease as a ‘silent killer’ often presents challenges to patients in understanding its impact on overall health. Thus, physician associates play a crucial role in ongoing discussion and education of CKD patients [46]. A program designed to enhance the quality of care for patients with CKD by providing personalized educational mailings and electronic alerts to their primary care providers during office visits has been effective. The program resulted in an increase in the screening rates for urine microalbumin, leading to better identification of patients who need more intensive management [47]. In this study, almost 20% of patients did not agree with their CKD diagnosis. This is a crucial finding that highlights the importance of involving patients in the diagnosis of kidney disease, as it forms the basis for the development of effective CKD management programs.
The cost of guideline-directed treatment
In high income countries, adoption of guideline-directed treatments for cardiorenal diseases is often impeded by high medication costs, low reimbursement rates, and the financial strain associated with clinical monitoring and medication adjustments [16]. The addition of finerenone to a hypothetical US health plan demonstrated moderately increased costs over a 3-year course. During this same time frame, minor cost savings were noted secondary to lower adverse renal and cardiovascular outcomes compared to standard care alone [48]. Furthermore, for Medicare Part D beneficiaries in 2019, the out-of-pocket costs for sodium-glucose cotransporter 2 inhibitors were at least $1,000 USD yearly, while those for Glucagon-Like Peptide-1 Receptor Agonists were over $1500 USD [49]. These costs may not be feasible for anyone, and especially burdensome on older or socially disadvantaged patients [49].
Lack of referral coordination across different healthcare settings
Several barriers hinder the coordinated management of DKD, including the presence of multiple comorbidities, insufficient education and awareness among ethnic minorities, communication challenges between primary care providers and the multiple specialists, and a shortage of multidisciplinary care teams at clinics [50]. Although telehealth is a convenient option for referral, limited virtual physical examinations and access to technology are major concerns [51].
Telehealth contributed to mistrust among some patients. This was most consistently expressed among patients of color who preferred to see the clinician in person and read their body language. However, older adults may find it more justifiable to use due to factors such as convenience, perceived safety, engagement of care partners, and improved understanding of the patients' home environments by clinicians [51].
Unstandardized guidelines in providing care to CKD patients
Diabetic patients with comorbid CKD and CVD could have different overlapping guideline-directed medical therapies, which represents a challenge in optimizing resources. However, the consensus between specialties guidelines is increasing [52]. The latest guidelines of different scientific societies including the European Society of Cardiology (ESC), the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists, and the ADA-KDIGO consensus report recommend the use of finerenone as a treatment option for DKD [9, 53, 54]. Further research is necessary to explore implementing multidisciplinary guidelines for DKD patient referrals back to the primary care provider. Multidisciplinary guidelines will ensure consistent recommendations through incorporating the opinions of patients, primary care providers, and the related specialties [40].
Conclusion
Re-envisioning of the physician associates’ role in primary care can facilitate adequate screening for CKD identification and provide personalized education and resources for patients with DKD. Based on the proposed multidisciplinary guidelines, physician associates should be more comfortable implementing care and goal-directed therapies to prevent the advancement of DKD.
Data availability
Data sharing not applicable to this article as no datasets were generated or analyzed during the development of this review article.
Abbreviations
- KDIGO:
-
Kidney Disease: Improving Global Outcomes
- CKD:
-
Chronic Kidney Disease
- CVD:
-
Cardiovascular Disease
- DKD:
-
Diabetic Kidney Disease
- T2DM:
-
Type 2 Diabetes
- UACR:
-
Urinary Albumin-to-Creatinine Ratio
- RASi:
-
Renin-angiotensin system inhibitors
- SGLT-2i:
-
Sodium-Glucose Cotransporter 2 Inhibitors
- nsMRA:
-
Nonsteroidal Mineralocorticoid Receptor Antagonist
- GLP-1Ras:
-
Glucagon-Like Peptide-1 Receptor Agonists
- PAs:
-
Physician Associates
- FDA:
-
Food and Drug Administration
- ESKD:
-
End Stage Kidney Disease
- NICE:
-
The National Institute for Health and Care Excellence
- HbA1c:
-
Hemoglobin A1c
- OTC:
-
Over-The-Counter
- PCP:
-
Primary Care Providers
References
Kovesdy CP (2022) Epidemiology of chronic kidney disease: an update 2022. Kidney Int Supplements 12(1):7–11. https://doi.org/10.1016/j.kisu.2021.11.003
CDC (2023) Chronic Kidney Disease in the United States 2023(22 July)
Thomas MC, Brownlee M, Susztak K, Sharma K, Jandeleit-Dahm KAM, Zoungas S et al (2015) Diabetic kidney disease. Nat Rev Dis Primers 1(1):15018. https://doi.org/10.1038/nrdp.2015.18
Levey AS, Eckardt KU, Dorman NM, Christiansen SL, Cheung M, Jadoul M et al (2020) Nomenclature for kidney function and disease: executive summary and glossary from a kidney disease: improving global outcomes consensus conference. Transplantation 104(10):1986–1994. https://doi.org/10.1097/TP.0000000000003360
Delgado C, Baweja M, Crews DC, Eneanya ND, Gadegbeku CA, Inker LA et al (2022) A unifying approach for GFR estimation: recommendations of the NKF-ASN task force on reassessing the inclusion of race in diagnosing kidney disease. Am J Kidney Dis 79(2):268–288. https://doi.org/10.1053/j.ajkd.2021.08.003. (e1)
Stevens PE, Levin A (2013) Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med 158(11):825–830. https://doi.org/10.7326/0003-4819-158-11-201306040-00007
Matsushita K, Jassal SK, Sang Y, Ballew SH, Grams ME, Surapaneni A et al (2020) Incorporating kidney disease measures into cardiovascular risk prediction: development and validation in 9 million adults from 72 datasets. EClinicalMedicine 27:100552. https://doi.org/10.1016/j.eclinm.2020.100552
Fox CS, Matsushita K, Woodward M, Bilo HJ, Chalmers J, Heerspink HJL et al (2012) Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis. The Lancet 380(9854):1662–1673. https://doi.org/10.1016/s0140-6736(12)61350-6
de Boer IH, Khunti K, Sadusky T, Tuttle KR, Neumiller JJ, Rhee CM et al (2022) Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care 45(12):3075–3090. https://doi.org/10.2337/dci22-0027
Lewis EJ, Hunsicker LG, Bain RP, Rohde RD (1993) The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. New Engl J Med 329(20):1456–1462. https://doi.org/10.1056/nejm199311113292004
Yang Q, Lang Y, Yang W, Yang F, Yang J, Wu Y et al (2023) Efficacy and safety of drugs for people with type 2 diabetes mellitus and chronic kidney disease on kidney and cardiovascular outcomes: a systematic review and network meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 198:110592. https://doi.org/10.1016/j.diabres.2023.110592
Naaman SC, Bakris GL (2023) Diabetic nephropathy: update on pillars of therapy slowing progression. Diabetes Care 46(9):1574–1586. https://doi.org/10.2337/dci23-0030
Agarwal R, Filippatos G, Pitt B, Anker SD, Rossing P, Joseph A et al (2022) Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis. Eur Heart J 43(6):474–484. https://doi.org/10.1093/eurheartj/ehab777
Stevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK et al (2024) KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int 105(4):S117–S314. https://doi.org/10.1016/j.kint.2023.10.018
Hsu HT, Chiang YC, Lai YH, Lin LY, Hsieh HF, Chen JL (2021) Effectiveness of multidisciplinary care for chronic kidney disease: a systematic review. Worldviews Evid-Based Nurs 18(1):33–41. https://doi.org/10.1111/wvn.12483
Nee R, Yuan CM, Narva AS, Yan G, Norris KC (2023) Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease. Nephrol Dial Transplant 38(3):532–541. https://doi.org/10.1093/ndt/gfac283
Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P et al (2020) Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes. New Engl J Med 383(23):2219–2229. https://doi.org/10.1056/NEJMoa2025845
Pitt B, Filippatos G, Agarwal R, Anker SD, Bakris GL, Rossing P et al (2021) Cardiovascular events with finerenone in kidney disease and type 2 diabetes. New Engl J Med 385(24):2252–2263. https://doi.org/10.1056/NEJMoa2110956
Frampton JE (2021) Finerenone: first approval. Drugs 81(15):1787–1794. https://doi.org/10.1007/s40265-021-01599-7
Kerendia [package insert]. Bayer HealthCare Pharmaceuticals Inc; 2022.
NICE: Finerenone for treating chronic kidney disease in people with type 2 diabetes. https://www.nice.org.uk/guidance/TA877/chapter/1-Recommendations (2023). Accessed 18 September 2023.
Di Lullo L, Lavalle C, Scatena A, Mariani MV, Ronco C, Bellasi A (2023) Finerenone: questions and answers—the four fundamental arguments on the new-born promising non-steroidal mineralocorticoid receptor antagonist. J Clin Med 12(12):3992. https://doi.org/10.3390/jcm12123992
Rossing P, Anker SD, Filippatos G, Pitt B, Ruilope LM, Birkenfeld AL et al (2022) Finerenone in patients with chronic kidney disease and type 2 diabetes by sodium-glucose cotransporter 2 inhibitor treatment: the FIDELITY analysis. Diabetes Care 45(12):2991–2998. https://doi.org/10.2337/dc22-0294
Rossing P, Agarwal R, Anker SD, Filippatos G, Pitt B, Ruilope LM et al (2022) Efficacy and safety of finerenone in patients with chronic kidney disease and type 2 diabetes by GLP-1RA treatment: a subgroup analysis from the FIDELIO-DKD trial. Diabetes Obes Metab 24(1):125–134. https://doi.org/10.1111/dom.14558
Herrington WG, Staplin N, Wanner C, Green JB, Hauske SJ, Emberson JR et al (2023) Empagliflozin in patients with chronic kidney disease. N Engl J Med 388(2):117–127. https://doi.org/10.1056/NEJMoa2204233
Heerspink HJL, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou FF et al (2020) Dapagliflozin in patients with chronic kidney disease. N Engl J Med 383(15):1436–1446. https://doi.org/10.1056/NEJMoa2024816
Perkovic V, Jardine MJ, Neal B, Bompoint S, Heerspink HJL, Charytan DM et al (2019) Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. New Engl J Med 380(24):2295–2306. https://doi.org/10.1056/nejmoa1811744
Green JB, Mottl AK, Bakris G, Heerspink HJL, Mann JFE, McGill JB et al (2023) Design of the COmbinatioN effect of FInerenone anD EmpaglifloziN in participants with chronic kidney disease and type 2 diabetes using a UACR Endpoint study (CONFIDENCE). Nephrol Dial Transplant 38(4):894–903. https://doi.org/10.1093/ndt/gfac198
De Boer IH, Caramori ML, Chan JCN, Heerspink HJL, Hurst C, Khunti K et al (2020) KDIGO 2020 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int 98(4):S1–S115. https://doi.org/10.1016/j.kint.2020.06.019
Jimenez-Marrero S, Cainzos-Achirica M, Monterde D, Vela E, Enjuanes C, Yun S et al (2024) Serum potassium abnormalities, renin-angiotensin-aldosterone system inhibitor discontinuation, and clinical outcomes in patients with chronic cardiovascular, metabolic, and renal conditions: a population-based analysis. Eur J Intern Med. https://doi.org/10.1016/j.ejim.2024.03.021
Bianchi S, Regolisti G (2019) Pivotal clinical trials, meta-analyses and current guidelines in the treatment of hyperkalemia. Nephrol Dial Transplant 34(Suppl 3):iii51–iii61. https://doi.org/10.1093/ndt/gfz213
Imasawa T, Saito C, Kai H, Iseki K, Kazama JJ, Shibagaki Y et al (2023) Long-term effectiveness of a primary care practice facilitation program for chronic kidney disease management: an extended follow-up of a cluster-randomized FROM-J study. Nephrol Dial Transplant 38(1):158–166. https://doi.org/10.1093/ndt/gfac041
AAMC: The complexities of physician supply and demand: projections from 2019 to 2034. https://www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-physician-shortage (2021). Accessed September 20 2023.
Leach B, Morgan P, Strand De Oliveira J, Hull S, Østbye T, Everett C (2017) Primary care multidisciplinary teams in practice: a qualitative study. BMC Family Pract. https://doi.org/10.1186/s12875-017-0701-6
Zhang RM (2023) Single institution prescribing pattern of finerenone in patients with type 2 diabetes and/or chronic kidney disease in the USA. Clin Kidney J. https://doi.org/10.1093/ckj/sfad073
Thomsen K, Zuber K, Davis J, Thomas G (2016) Improving treatment for patients with chronic kidney disease. JAAPA 29(11):46–53
National Kidney F (2012) KDOQI clinical practice guideline for diabetes and CKD: 2012 update. Am J Kidney Dis 60(5):850–886. https://doi.org/10.1053/j.ajkd.2012.07.005
Rossing P, Caramori ML, Chan JCN, Heerspink HJL, Hurst C, Khunti K et al (2022) KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int 102(5):S1–S127. https://doi.org/10.1016/j.kint.2022.06.008
Ashjian E, Clarke M, Pogue K (2023) Pharmacotherapy considerations with finerenone in the treatment of chronic kidney disease associated with type 2 diabetes. Am J Health-Syst Pharmacy. https://doi.org/10.1093/ajhp/zxad192
Van Dipten C, Van Dam DGHA, De Grauw WJC, Ten Dam MAGJ, Hermans MMH, Assendelft WJJ et al (2021) Referring patients with chronic kidney disease back to primary care: a criteria-based analysis in outpatient renal clinics. BMC Nephrol. https://doi.org/10.1186/s12882-021-02367-1
Davis J, Zuber K (2021) The changing landscape of PAs and NPs in nephrology. JAAPA 34(1):1–8
Link DK (2015) Chronic kidney disease: new paradigms in diagnosis and management. JAAPA 28(7):23–28. https://doi.org/10.1097/01.JAA.0000466586.10595.2e
Kawanami D, Takashi Y, Muta Y, Oda N, Nagata D, Takahashi H et al (2021) Mineralocorticoid receptor antagonists in diabetic kidney disease. Front Pharmacol 12:754239. https://doi.org/10.3389/fphar.2021.754239
Van Walraven C, Oake N, Jennings A, Forster AJ (2010) The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract 16(5):947–956. https://doi.org/10.1111/j.1365-2753.2009.01235.x
Jang YJ, Choy YS, Nam CM, Moon KT, Park E-C (2018) The effect of continuity of care on the incidence of end-stage renal disease in patients with newly detected type 2 diabetic nephropathy: a retrospective cohort study. BMC Nephrol. https://doi.org/10.1186/s12882-018-0932-3
Zuber K, Davis J (2018) The ABCs of chronic kidney disease. JAAPA 31(10):17–25
Sequist TD, Holliday AM, Orav EJ, Bates DW, Denker BM (2018) Physician and patient tools to improve chronic kidney disease care. Am J Manag Care 24(4):e107–e114
Dayer VW, Hansen RN, Singh R, Kong SX, Williamson T, Sullivan SD. Potential budget impact of finerenone in patients with chronic kidney disease and type 2 diabetes being treated with standard of care. Value in Health: ELSEVIER SCIENCE INC STE 800, 230 PARK AVE, NEW YORK, NY 10169 USA; 2022. p. S413-S.
Luo J, Feldman R, Rothenberger SD, Hernandez I, Gellad WF (2020) Coverage, formulary restrictions, and out-of-pocket costs for sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in the medicare Part D program. JAMA Netw Open 3(10):e2020969. https://doi.org/10.1001/jamanetworkopen.2020.20969
Junaid Nazar CM, Kindratt TB, Ahmad SM, Ahmed M, Anderson J (2014) Barriers to the successful practice of chronic kidney diseases at the primary health care level; a systematic review. J Renal Inj Prev 3(3):61–67. https://doi.org/10.1286/jrip.2014.20
Ladin K, Porteny T, Perugini JM, Gonzales KM, Aufort KE, Levine SK et al (2021) Perceptions of telehealth vs in-person visits among older adults with advanced kidney disease, care partners, and clinicians. JAMA Netw Open 4(12):e2137193. https://doi.org/10.1001/jamanetworkopen.2021.37193
Dubrofsky L, Lee JF, Hajimirzarahimshirazi P, Liu H, Weisman A, Lawler PR et al (2022) A unique multi- and interdisciplinary cardiology-renal-endocrine clinic: a description and assessment of outcomes Canadian. J Kidney Health Dis 9:205435812210812. https://doi.org/10.1177/20543581221081207
Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M et al (2022) American Association of clinical endocrinology clinical practice guideline: developing a diabetes mellitus comprehensive care plan-2022 update. Endocr Pract 28(10):923–1049. https://doi.org/10.1016/j.eprac.2022.08.002
Marx N, Federici M, Schutt K, Muller-Wieland D, Ajjan RA, Antunes MJ et al (2023) 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J. https://doi.org/10.1093/eurheartj/ehad192
Acknowledgements
The authors would like to thank the American Academy of Nephrology Physician Associates as they created and supported KIB (Kidneys in a Box). The authors would like to acknowledge the medical writing support provided by Khaled Shelbaya, MBBCh, MD, MMSc, of ILM Consulting Services, LLC., which was funded by Bayer US, LLC. The authors would also like to acknowledge the editorial support, visualization and graphical abstract development provided by Aqsa Dar, ScM, of ILM Consulting Services, LLC., which was funded by Bayer US, LLC. ILM Consulting Services, LLC. complied with the international guidelines for Good Publication Practice (GPP 2022).
Funding
Bayer US, LLC. funded the article processing charges for this article. Bayer US, LLC. also funded ILM Consulting Services, LLC. for medical writing support and publication management.
Author information
Authors and Affiliations
Contributions
All authors contributed to the writing and reviewing of each draft and reviewing and approving the final draft for submission. B.M.N.: conceptualization, writing—review & editing. H.W.: conceptualization, writing—review & editing.
Corresponding author
Ethics declarations
Conflict of interest
The authors, Becky M. Ness and Heidi Webb, do not have any competing interests in relation to this review article.
Ethical approval
Ethical approval for this review article was not applicable as it did not involve human participants and/or human tissues.
Informed consent to participate
Informed consent to participate was not applicable for this review article as it did not have any individual participants.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Ness, B.M., Webb, H. Finerenone: Who should prescribe it for CKD? The physician associate’s perspective. J Nephrol (2024). https://doi.org/10.1007/s40620-024-02015-5
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s40620-024-02015-5