16 Use Guideline-Directed Medical Therapy and Shared Decision-Making to Improve Outcomes CKD in the advanced stages is largely irreversible, but progression can be halted, even reversed, in earlier stages. Early detection through screening of at-risk individuals who may be asymptomatic, followed by early intervention using guideline-directed medical therapy (GDMT), are critical steps in reducing CKD progression and CKD-associated morbidity and mortality.18-introduction Lifestyle intervention, including weight control, physical activity, appropriate eating patterns and tobacco avoidance, is the basis of good CKM health. Clinicians have a substantial and growing collection of therapeutic options for those with disease already, not at risk for CVD or CKD. They can prevent adverse outcomes, such as kidney failure, particularly when used early in the course of disease. Just as risk reduction and therapeutic approaches to HF are based on Pillars of Therapy, so too are CKD and CKM health. Renin-angiotensin system (RAS) blockade using ACE inhibitors or ARBS emerged as the first pillar for CKD in the 1990s. More recent evidence has established SGLT2 inhibitors, a nsMRA and GLP-1 receptor agonists as additional pillars of treatment for CKD, intially in individuals with diabetes and increasingly in those without diabetes.19-Article highlights, 20-Gaps Between Knowledge and Implementation in Kidney Care, 21-Introduction Practice guidelines for CKD are clear, but application of GDMT is poor.20- Gaps Between Knowledge and Implementation in Kidney Care More than 15 years after the most recent CKD and T2D approvals of ACE inhibitors/ARBs in the United States, realworld data from electronic health records suggest uptake is about 40% after 90 days.20-Gaps Between Knowledge and Implementation in Kidney Care. Pg. 408 SGLT2 inhibitors can reduce risk of substantial decline in eGFR, kidney failure and death in individuals with CKD, HF and CVD by about 40%. These benefits are additive to risk reductions seen with RAS blockade, yet uptake of SGLT2 inhibitors is only about 6% after 90 days. Uptake of GLP1 receptor agonists is similarly low.20- Gaps Between Knowledge and Implementation in Kidney Care First-line GDMT focuses on blood pressure, glucose and lipid management22-First-line GDMT, 7- Chapter3 including RAS blockade plus SGLG2 inhibition for individuals with or without diabetes.7-Figure 18, 3.7 Either an ACE inhibitor or ARB at maximum tolerated dose are appropriate RAS inhibitors.7-Figure 18, 3.6 Target blood pressure for most patients is <120 mm Hg or <130 mm Hg systolic depending on risks of CVD and CKD and overall health status.7-Figure 18, 3.4, 20-Figure 3 Treating CKD is more successful with a holistic approach that includes risk modification and GDMT.7-Figure 18 Healthy lifestyle interventions are the foundation for GDMT, including healthy diet, physical activity, weight management and cessation of tobacco use. The same interventions are also recommended to reduce CVD risk.22-Foundation: healthy lifestyle and management of traditional risk factors
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