Background:

My kidney doctor keeps mentioning goal-directed kidney therapy, or GDKT. The provider continues to discuss the need for blood pressure control and other multiple medical therapies to prevent the progression, or worsening, of chronic kidney disease. Are all of these therapies really necessary?

Please answer the following questions:

What is goal-directed kidney therapy?

Goal-directed kidney therapy, or GDKT, is a philosophy of using “pillar of care” therapy to optimize your medical treatment to prevent worsening of kidney function. It resembles goal-directed medical therapy (GDMT) which is employed in the treatment of congestive heart failure.

What is a pillar of care?

Pillars to demonstrate goal-directed kidney therapy

Pillars keep the structure upright. It takes multiple pillars to keep a structure from falling.

GDKT involves prescribing multiple therapies, writing them at the highest tolerated doses, aware of the risks of side effects, with the goal of optimizing the chances that the kidneys will not progress to kidney failure and the need for kidney replacement therapy (dialysis) and heart problems. We want to prevent the kidneys from turning into rubble.

Rubble demonstrating what happens when a patient does not receive goal directed kidney therapy — The remains of something that has been destroyed are referred to as rubble. And what can happen when a patient does not receive GDKT? The kidneys are trashed, progressing towards failure.

What are some commonly prescribed therapies and strategies used in goal-directed kidney therapy?

Blood pressure control

includes RAAS inhibition: such as losartan or lisinopril

Sodium-glucose cotransporter-2 inhibitors (SGLT2i)

such as empagliflozin or dapagliflozin

Glucagon-like peptide-1 (GLP-1) agonists

Mineralocorticoid Receptor Antagonists (MRA)

Statins such as rosuvastatin or atorvastatin

Reduction of proteinuria using some of the above therapies

Why does goal-directed kidney therapy matter?

We are now focusing on the eGFR slope decline in addition to the stage of CKD and the amount of albumin in the urine, the uACR (see the discussion below). Through implementing the pillars of care, specifically goal-directed kidney therapy (GDKT), we have the potential to avert the occurrence of complete renal failure and the subsequent requirement for kidney dialysis.

The slope of the eGFR declines when using goal directed kidney therapy.

A pillar-of-care effect of goal-directed kidney therapy to slow the progression of CKD was found. By incorporating blood pressure regulation, SGLT2 inhibition, RAAS inhibition, MRA, and GLP-1 (not shown), the eGFR curve’s slope shifts upwards toward the ageing-associated decline curve (the gray/nearly horizontal line). GDNT prolongs a patient’s life without requiring dialysis by reducing the rate at which the patient’s eGFR declines, which is a compelling argument in favor of adopting these therapies when appropriate.

Up arrow — As GDNT is added, the eGFR slope improves. See the yellow line above compared with the gray one.

Important: This figure is a historical representation of how GDKT might help you. As new therapies were discovered, the patient benefit of using these pillars meant more time off dialysis. And it can now be measured in years! That said, your provider does not have to prescribe the therapies in the order shown. One or more of the pillars may need to be omitted if you cannot tolerate a particular medication because of a side effect.

Multiple therapeutics require experts to be aware of and able to optimize your medications, tailoring the treatment plan to the individual, and using as many of these medications as are needed to improve the eGFR slope as much as possible. Please speak with your providers for the most effective approach.

Additional discussion:

We have added the kidney heat map in the learn more section and to help assess risk. We have also provided a foundational link for those who wish to dive further into this topic.

➡️Learn More⬅️

The chronic kidney disease (CKD) heat map is shown below:

Chronic Kidney Disease Heat Map demonstrating the risk for progression of CKD — CKD Heat map is broken down into GFR stage and albuminuria category. There are only two low-risk categories on the entire map! Every other situation increases the risk for progression of CKD, and for these categories, treatment should be considered.

Note: more albumin in the urine is higher risk for progression of CKD. Worsening CKD is also higher risk. Use goal-directed kidney therapy (GDKT) to decrease the risk of progression of CKD and kidney failure / end stage kidney disease.

Inspiration: Expanding the therapy options for diabetic kidney disease, Nature Reviews

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