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Navigating CKD through precision care
Navigating CKD Through Patient-Centered and Multidisciplinary Precision Care

Released: June 19, 2025

Expiration: June 18, 2026

Jay Wish
Jay Wish, MD
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Key Takeaways
  • SGLT2 inhibitors, renin–angiotensin–aldosterone system blockers, and nonsteroidal mineralocorticoid receptor antagonists are all foundational therapies for managing patients with chronic kidney disease (CKD).
  • Healthcare professionals should determine the cause of disease progression or worsening renal function before prematurely stopping patients’ CKD treatment.
  • A multidisciplinary care approach to care is essential since patients with CKD often present with comorbidities like diabetes, heart failure, and hypertension.

The 2 interactive case challenges involving Mr. Robert Hill offer a compelling view into the intricate care required for patients with chronic kidney disease (CKD) and type 2 diabetes (T2D), hypertension, and/or heart failure. Mr. Hill is a 65-year-old man with T2D, hypertension, heart failure with preserved ejection fraction, stage 3 CKD, a BMI of 30.8 kg/m², and a history of smoking. His medications include metformin, lisinopril, atorvastatin, empagliflozin, and finerenone. From a nephrologist’s perspective, this patient case exemplifies how critical evidence-based, patient-centered decision-making is, especially in the context of multifaceted comorbidities. It also underscores how small missteps, such as premature medication adjustments or delayed specialist referrals can have significant downstream consequences. Furthermore, they highlight how coordinated multidisciplinary strategies can dramatically alter the disease trajectory for patients with CKD.

Guideline-Concordant CKD Management
In both interactive case challenges, the early and deliberate application of foundational therapies like SGLT2 inhibitors and renin–angiotensin–aldosterone system blockers played a pivotal role in slowing disease progression. The initiation of empagliflozin and titration of lisinopril were well-timed interventions that aligned with the 2024 Kidney Disease Improving Global Outcomes and 2025 American Diabetes Association guidelines. These agents are now recognized as cornerstones of care in CKD management because of their dual protective benefits across the renal and cardiovascular systems. Yet a common pitfall in real-world practice is the premature discontinuation of these therapies when patients experience adverse events like dizziness or a marginal estimated glomerular filtration rate (eGFR) decline. In Mr. Hill’s case, rather than removing these agents, his care team explored alternative explanations for his symptoms such as orthostatic hypotension and used pragmatic interventions like nighttime dosing and hydration guidance. These steps preserved the therapeutic benefits of key therapies while addressing the underlying cause of discomfort, which is illustrating a clinical approach that is both judicious and patient-focused.

Another instructive aspect of this patient case is the thoughtful use of finerenone. A nonsteroidal mineralocorticoid receptor antagonist, finerenone, has emerged as a significant adjunct in managing persistent albuminuria in patients with T2D who are already receiving SGLT2 inhibitors and renin–angiotensin–aldosterone system blockers. Its benefits, proven in the FIDELIO-DKD and FIGARO-DKD trials, include both renal and cardiovascular protection. However, its use must be accompanied by diligent potassium monitoring because of the risk of hyperkalemia. The decision to initiate finerenone in Mr. Hill’s care was appropriately cautious and underpinned by close laboratory follow-up, a model that should be mirrored in broader practice to ensure patients’ safety without forfeiting benefit.

Although dietary intervention often receives insufficient attention in clinical care, it emerged as a key therapeutic tool in the interactive case challenges. The referral to a renal dietitian and implementation of targeted sodium and protein restriction yielded measurable benefits in eGFR stabilization and reduction in albuminuria. These outcomes reinforce the idea that lifestyle interventions remain a foundational (not supplemental) treatment strategy complementary to pharmacologic therapy in CKD. It is worth noting that poorly guided dietary restrictions can lead to malnutrition, especially among patients with T2D. That is why individualized, expert-led nutritional plans are critical, ensuring that dietary modifications are sustainable, safe, and clinically effective.

Timing of Specialist Referral Is Key
The issue of nephrology referrals also reveals important nuances in CKD management. The first interactive case challenge demonstrated an appropriate escalation to specialist care when Mr. Hill’s eGFR fell to <50 mL/min/1.73 m² and albuminuria remained persistently elevated (>150 mg/g). This decision reflects a guideline-based and outcomes-oriented strategy. By contrast, the second interactive case challenge revealed a decision to not refer to specialist care given the patient’s stable kidney function, controlled blood pressure, and improved proteinuria. Here lies a delicate balance: Overreferral of stabilized patients can dilute nephrology resources and fragment care, and underreferral for those with high-risk markers may result in delayed essential interventions. The key is understanding the thresholds for referral not as rigid rules, but as clinical inflection points requiring context, pattern recognition, and collaboration between primary and specialty care.

A particularly insightful turn in the second interactive case challenge was the evaluation of Mr. Hill’s mild exertional dyspnea and slight deterioration in kidney function. Rather than reflexively increasing antihypertensive dosing or discontinuing effective agents, the clinical team pursued NT-proBNP testing to explore heart failure exacerbation as a possible etiology. This decision reflects an important clinical principle: CKD progression is not always because of worsening intrinsic kidney disease. Reversible or parallel processes, such as fluid overload from heart failure, can mimic CKD deterioration. Employing cardiac biomarkers, assessing volume status, and adjusting diuretic therapy accordingly allowed the team to stabilize Mr. Hill’s renal function and address his cardiovascular risk.

Multidisciplinary and Patient-Centered Care
Ultimately, both case challenges showcased the power of integrated, multidisciplinary care. Mr. Hill’s improvement did not stem from a single therapeutic maneuver but from a series of carefully coordinated decisions across specialties. Primary care initiated appropriate screening and pharmacologic therapy, cardiology contributed insights into volume status and medication tolerability, nephrology optimized risk stratification and long-term planning, and nutrition provided the lifestyle scaffolding needed to enhance pharmacologic outcomes. Each role, executed with intention and mutual communication, contributed to a broader arc of success.

This patient case not only reinforced best practices but also revealed where clinical inertia or missteps commonly arise. Whether it is failing to address reversible symptoms before modifying treatment, not maximizing dietary resources, or delaying specialist referral, the stakes in CKD management are high. Precision, patience, and partnership are the antidotes. By adhering to guideline-concordant care and tailoring interventions to each patient's unique trajectory, healthcare professionals can meaningfully slow CKD progression, improve cardiovascular outcomes, and elevate the standard of care for this growing and vulnerable patient population.

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