Trends in Utilization of Guideline-Directed Cardiorenal Protective Therapies for Chronic Kidney Disease in Patients with Cardiovascular Morbidity: Real World Data from Two Cross-Sectional Snapshots (HECMOS I and II)

Abstract

Introduction: Chronic kidney disease (CKD) affects roughly 10% of the global population and significantly increases cardiovascular risk. While renin-angiotensin system inhibitors (RASi) remain a therapeutic mainstay, recent evidence supports the renoprotective value of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and finerenone. This study evaluated the real-world use of guideline-directed medical therapy (GDMT) among patients with cardiorenal disease in Greece and explored factors influencing prescribing patterns. Methods: The Hellenic Cardiorenal Morbidity Snapshots (HECMOS 1 and 2) enrolled all cardiology inpatients across Greece on 3 March, 2022, and 5 June, 2024. Comorbidities and medication data were based on self-report and chart review. CKD patients eligible for SGLT2i and finerenone were identified per guideline criteria. Multivariable logistic regression was used to identify predictors of SGLT2i use. Results: From a total of 923 and 1222 patients enrolled in HECMOS 1 and 2, CKD was present in 26% and 27%, respectively. SGLT2i use prior to hospitalization rose from 15% in HECMOS 1 to 30.4% in HECMOS 2. In HECMOS 1, diabetes mellitus was the strongest predictor of SGLT2i use (OR 12.01, 95% CI 3.31-45.56, p < 0.001), while heart failure predicted use in HECMOS 2 (OR 4.10, 95% CI 1.70-9.88, p = 0.002). Finerenone was prescribed in only 1.7% of eligible patients in HECMOS 2. RASi usage among CKD patients remained stable across both cohorts (42.1% vs. 41.7%), with renal dysfunction showing no impact on prescribing patterns. Conclusions: SGLT2i use in patients with CKD and cardiovascular disease doubled over 2 years, indicating progress in implementing GDMT. However, overall use of disease-modifying therapies remains suboptimal, underscoring the need for further improvement in real-world care.

Keywords: SGLT2 inhibitor; chronic kidney disease; finerenone; heart failure.

Figure 1

Flowchart of patient selection in HECMOS 1 and 2. CKD: chronic kidney disease, SGLT2i: sodium-glucose cotransporter-2 inhibitor.

Figure 2

Guideline-directed medical therapy prescription prior to admission in CKD HECMOS. SGLT2i: sodium–glucose cotransporter-2 inhibitor, RASi: renin-angiotensin system inhibitor. The exact number of patients is shown above the bars.

Figure 3

SGLT2i prescription in overall chronic kidney disease (CKD), CKD with type 2 diabetes mellitus (T2DM), and CKD with heart failure (HF).