Since 1990s, Slower Declines in GFR with Standard Care for CKD

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Outcomes data on standard-of-care (SOC) control groups from chronic kidney disease (CKD) treatment trials over the past 3 decades suggest slower declines in kidney function, reports a systematic review in the American Journal of Kidney Diseases.

The researchers analyzed “secular trends” in glomerular filtration rates (GFRs) among patients with nondialysis CKD randomized to SOC treatment in clinical trials published from 1990 to 2023. A meta-analysis included data on 32,202 patients assigned to SOC groups in 92 trials.

The analysis suggested dramatic improvement in the rate of GFR decline among patients assigned to SOC. Annual decline in GFR was 5.44 mL/min/1.73 m2 for studies published from 1991 to 2000 versus 3.20 mL/min/1.73 m2 from 2011 to 2023, a reduction of approximately 41%. This was despite increasing age (from 51 to 58 years, respectively) and comorbidity in the study cohorts.

Slowing of estimated GFR (eGFR) decline was associated with rising use of renin-angiotensin-aldosterone system inhibitors: 16% from 1991 to 2000 versus 85% from 2011 to 2023. Other significant factors included improved blood pressure control and decreased proteinuria. In a multivariable meta-regression model, age and baseline proteinuria level were the only factors independently associated with eGFR decline.

The researchers note some key limitations of their observational study, including variation in methods of assessing GFR.

Recent studies have provided evidence that “multifaceted nephrology care” can substantially slow the rate of progression of CKD—representing a major paradigm shift in treatment. “Nevertheless,” the researchers write, “solid evidence demonstrating that CKD management has improved over the years is still lacking.”

The meta-analysis shows substantial improvement in rates of GFR decline among patients assigned to SOC treatment for nondialysis CKD from the 1990s to the current decade. The authors discuss relevant changes in patient characteristics and evidence-based treatment for CKD, along with implications for future randomized clinical trials [Garofalo C, et al. Secular trend in GFR decline in non-dialysis CKD based on observational data from standard of care arms of trials. Am J Kidney Dis, published online November 11, 2023. doi: 10.1053/j.ajkd.2023.09.014].