Key takeaways:

• Fewer than 10% of nephrologists prescribe glucose-lowering drugs.
• Nephrologists are well positioned to holistically care for patients with cardiovascular-kidney-metabolic syndrome.

Recent data reveal a striking paradox: While 73% of endocrinologists prescribe glucose-lowering medications, fewer than 10% of nephrologists do.

This difference highlights a critical opportunity. Historically, nephrologists have deferred metabolic management to primary care or endocrinology, but the interconnected reality of cardiovascular-kidney-metabolic (CKM) syndrome requires a more holistic approach.

And because patients with advanced kidney disease see their nephrologist more frequently than their primary care physician or other specialists, nephrologists are uniquely positioned to close this treatment gap.

Because kidney disease is inextricably linked to CV and metabolic drivers, nephrologists are better positioned than ever to holistically care for patients’ metabolic needs. For patients with advanced chronic kidney disease, our goal as nephrologists extends beyond protecting renal function and preparing for transplant to reducing the risk for CV mortality — which remains patients’ primary cause of death — and preserving quality of life.

Severe access challenges — including a projected shortage of up to 40,400 PCPs by 2036 and nearly 70% of counties lacking access to endocrinologists — mean nephrologists have the opportunity to fill important gaps in care.

By proactively leveraging SGLT2 inhibitors and GLP-1 receptor agonists, nephrologists can drive earlier, comprehensive interventions within kidney care and across the entire CKM continuum.

The case for combination therapy

Recent data support the simultaneous use of SGLT2 inhibitors and GLP-1 receptor agonists in patients with CKD and diabetes through distinct, complementary mechanisms of action.

Key benefits for these therapies include:

• CV risk reduction: demonstrated by a 13% to 14% reduction in major adverse CV across major trials, including LEADER and SUSTAIN 6;
• further kidney risk reduction: recently demonstrated in the FLOW trial for semaglutide; and
• weight loss: effective management of metabolic drivers.

Despite these benefits, uptake remains limited in advanced CKD populations. For Medicare beneficiaries with stage 4 or 5 CKD in 2023, only 15.7% were receiving SGLT2 inhibitors, and only 13.8% were receiving GLP-1 medications. While these limited rates may partially reflect FDA recommendations against initiating SGLT2 inhibitors at lower eGFR levels, this further highlights the need for earlier identification of and access to specialized kidney care.

Addressing barriers to implementation

Clinical effectiveness alone is not sufficient to drive impact. Real-world use of GLP-1 receptor agonists is often limited by cost, access restrictions and tolerability challenges, particularly gastrointestinal adverse events that contribute to discontinuation.

To lead this prescribing revolution, nephrologists must move beyond clinical support and actively champion systemic changes. This means advocating for the expansion of coverage for these medications, directly challenging restrictive access policies and building prior-authorization support into practice workflows.

By doing so, we can increase access to combination therapies for our most at-risk populations, working to bridge the gaps in preventive care and drastically improve long-term health outcomes.

Looking ahead

As we look to the future, the nephrology community awaits and evaluates results of ongoing GLP-1 studies, specifically in end-stage kidney disease, which may help unlock benefits for transplant wait-listing and overall mortality.

A retrospective observational study on patients dialyzing in DaVita facilities demonstrated an association between GLP-1 medication use and outcomes for patients receiving dialysis. The evaluation reviewed a cohort of hemodialysis patients with diabetes who were prescribed a GLP-1 drug alongside a matched cohort of patients who were not prescribed a GLP-1. Patients receiving the GLP-1 experienced a 17% lower risk for mortality and a 9% reduction in hospitalizations.

Further research will provide greater clarity for patients with ESKD, but there is ample clinical evidence right now to embrace these therapies for many patients with CKD —changing the trajectory of kidney disease through a holistic approach that addresses multiple CKM disease pathways.

For more information:

Jeffrey Giullian, MD, MBA, FASN, is chief medical officer of DaVita Inc. and a Healio | Nephrology News & Issues Editorial Advisory Board Member. He can be reached at jeffrey.giullian@davita.com.