17 A Toolkit for Health Care Professionals Screening for Kidney Disease to Reduce CVD Risk Treatment In adults aged 18–49 years with CKD but not treated with chronic dialysis or kidney transplantation, we suggest statin treatment in people with one or more of the following: • known coronary disease (myocardial infarction or coronary revascularization) • diabetes mellitus • prior ischemic stroke • estimated 10-year incidence of coronary death or nonfatal myocardial infarction >10%..7-Figure 18, 3.15, 20-Figure 3 In individuals without CKD, statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician– patient risk discussion. Targeted therapies for complications include management of hyperglycemia per the KDIGO 2022 guidelines for diabetes management in CKD7 summary of recommendation statements and practice points and include the use of a GLP-1 receptor agonist,7-3.9 nsMRA in those with T2D7-3.8 or dihydropyridine CCB and/ or diuretic if needed to achieve blood pressure goal, followed by steroidal MRA if needed for resistant hypertension if eGFR ≥45. ASCVD risk should be managed using ezetimibe and a PCSK9 inhibitor based on risk levels and lipids. Use the same principles employed to diagnose and manage ASCVD and atrial fibrillation as in those without CKD. For individuals living with T1D and CKD, current GDMT is RAS blockade using ACE inhibitor or ARB, statin and insulin.17-Figure 1, 1.1 Safety and efficacy of SGLT2 inhibition in T1D have not been established.17-Recommendation 1.3.1 Barriers to GDMT Low rates of screening are early barriers to the implementation of kidney and heart protective GDMT. Limited health care professional awareness of subspecialties may contribute to low prescription rates for GDMT therapies shown to protect kidneys and hearts. Inconsistencies across professional society guidelines may add to provider confusion and uncertainty. High rates of discontinuation of kidney and heart protective drugs are another barrier to GDMT. Multiple factors are related to adherence and discontinuation, including side effects, cost, access, insurance plan coverage, health inequities related to social determinants of health (SDOH) and more. Practical strategies that are patient-centered and leverage multidisciplinary expertise are needed.24-Challenges in the Implementation of Kidney Protective and Cardioprotective Therapies, Strategies to Improve the Implementation of Kidney Protective and Cardioprotective Therapies
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