Nihar R. Desai, MD, MPH

CKD Guidelines and Adherence Across Specialties

CKD Guidelines and Adherence Across Specialties,’ the panelists explore the following questions:

What are the differences between the current guideline (ie, NKF, KDIGO 2025, ADA) recommendations for CKD diagnosis and staging in clinical practice?

How are these guidelines applied in practice across specialists such as primary care, nephrology, cardiology, and endocrinology?

Can you comment on guideline adherence across primary care and specialties including nephrologists, cardiologists, endocrinologists?

How can guideline adherence be elevated in clinical practice to improve CKD care?


The panelists examine how clinicians can navigate the many overlapping guidelines related to diagnosing chronic kidney disease (CKD), emphasizing that there is strong consistency rather than contradiction across professional societies. They highlight that the KDIGO framework—integrating eGFR and albuminuria (uACR) in a heat map staging system—is broadly endorsed across cardiology, endocrinology, diabetes, and hypertension guidelines and provides critical insight into both kidney and cardiovascular risk. Despite this consensus, the panel underscores a major gap between guidelines and real-world practice, noting that only a minority of eligible patients currently receive recommended CKD screening. The discussion concludes with practical strategies to improve diagnosis at scale, including clinician education on uACR, leveraging EHR and AI tools, shared accountability across specialties, and a proactive, public health–focused approach to preventing progression to end-stage kidney disease.

The next episode in this series, ‘Quality of Life Impact of Delayed CKD Diagnosis,’ features the panelists advancing their conversation on chronic kidney disease and focusing on how early detection provides a modifiable opportunity to deploy risk-mitigating therapies before patients face the profound emotional, physical, and mortality risks associated with dialysis and end-stage disease. The experts emphasize that treating CKD early not only preserves kidney function but acts as a critical multiplier for reducing systemic cardiovascular complications and improving long-term quality of life.

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Experts explain how uACR and eGFR testing reveals hidden CKD, links to heart risk, and guides early, patient-centered care.

Addressing Chronic Kidney Disease (CKD) Prevalence and Patient Awareness in Cardiorenal Metabolic Care

Welcome back to another HCPLive Peer Exchange series. In this episode titled, ‘Addressing Chronic Kidney Disease (CKD) Prevalence and Patient Awareness in Cardiorenal Metabolic Care’, the moderator, Dr. Muthiah Vaduganathan, leads the conversation about the following questions:

How prevalent is chronic kidney disease (CKD) in your patient population, and which comorbidities most commonly coexist at the time of presentation?

How do you communicate with patients who have type 2 diabetes or cardiovascular disease and are often unaware of CKD as a comorbidity, and how do you improve their understanding of the associated risks?

Panelists, Dr. Nihar Desai, Dr. Pamela Kushner, and Dr. Craig Beavers, highlight that CKD prevalence in high-risk populations—particularly those with overlapping diabetes, hypertension, and obesity—can reach as high as 20% to 40%, far exceeding the national average. The experts emphasize the "silent" nature of the disease, noting a significant gap between clinical diagnosis and patient awareness, which often leads to emotional distress when the condition is finally disclosed. To improve literacy and empower patients, the speakers advocate for an integrated Cardiorenal Metabolic framework, using proactive testing (such as uACR and eGFR) and gentle, transparent communication to link kidney health directly to cardiovascular outcomes. Finally, they underscore that formalizing a CKD diagnosis is not only vital for individual treatment escalation but also critical for informing public policy and securing community health resources.

In the next episode, ‘CKD Guidelines and Adherence Across Specialties’, panelists will continue their discussion on chronic kidney disease and highlight that while clinical guidelines are remarkably consistent in advocating for the KDIGO "heat map" and combined eGFR/uACR testing, a significant implementation gap remains with only 20% of high-risk patients being properly screened. They argue for a unified "cardiorenal metabolic" ownership model that leverages EHR tools and simplified patient analogies to bridge this gap and prioritize proactive, guideline-directed care.

Learn how uACR and eGFR uncover hidden CKD, sharpen cardiovascular risk, and guide patient-friendly conversations for earlier, smarter care.

Finerenone Outperforms Spironolactone for Heart Failure Exacerbation in HFpEF, With Nihar Desai, MD, MPH

Finerenone use was associated with lower risks of heart failure exacerbation and all-cause mortality compared to spironolactone in patients with 

heart failure with preserved ejection fraction (HFpEF)

, based on a recent retrospective cohort study.

Phase II studies have associated finerenone with reduced risks of hyperkalemia and deterioration in kidney function when compared with spironolactone and eplerenone in patients with 

. The recent FINEARTS-HF trial has also highlighted finerenone, investigating its efficacy in reducing heart failure hospitalization in patients with HFpEF.

“Spironolactone is a very important and highly effective therapy. The evidence to support its use in patients with reduced ejection fraction heart failure are unequivocal,” Nihar Desai, MD, MPH, associate professor of medicine at Yale School of Medicine and a contributing author in this study, told 

 in an exclusive interview. “However, the question arises regarding mid-range and preserved ejection fraction patients; spironolactone actually doesn’t have that as part of its indications. In contrast, using finerenone in those patients with an EF of ≥40% saw substantial clinical benefits.”

Desai and colleagues performed a retrospective observational cohort study via the TriNetX database, identifying all patients with a diagnosis of HFpEF. The team notes the potential limitations of TriNetX’s lack of additional datapoints, such as echocardiographic parameters and NYHA functional class, and the possible misclassification of patients within the HFpEF category.

Patients were then further stratified based on finerenone or spironolactone use within 1 year of diagnosis. Concomitant spironolactone and/or finerenone use was excluded in both cohorts. The primary outcomes of the analysis were first or subsequent heart failure exacerbations, acute myocardial infarction, hypokalemia, ischemic stroke, all-cause mortality, sudden cardiac death, and hyperkalemia within a 1-year follow-up period. Acute myocardial infarction and ischemic stroke were included as secondary endpoints.

Ultimately, the study included 254,417 patients with HFpEF; after propensity score matching, 491 patients were enrolled in each cohort, yielding a total of 982 participants. During the follow-up, the finerenone arm saw substantially lower statistically significant risk of heart failure exacerbation (55.2% vs 72.9%; HR, 0.63; 95% CI, 0.54-0.74; 

 <.001). Additionally, finerenone was associated with lower risks of all-cause mortality compared to spironolactone (4.1% vs 11.8%; HR, 0.38; 95% CI, 0.23-0.64; 

Investigators also recorded a lower risk of hypokalemia in the finerenone cohort versus spironolactone (8.4% vs 15.1%; HR, 0.58; 95% CI, 0.4-0.85; 

 <.001). Despite not being statistically significant, similar trends were noted for hyperkalemia (13.8% vs 16.1%; HR, 0.96; 95% CI, 0.69-1.33). Sudden cardiac death was rare across both cohorts, affecting only 1 patient in the spironolactone arm and 10 in the finerenone arm.

Desai and colleagues also performed subgroup analyses for patients with CKD and 

. Those with CKD saw substantially lower risk of heart failure exacerbation with finerenone versus spironolactone (59.4% vs 74.1%; HR, 0.63; 95% CI, 0.53-0.74; 

 <.001). The diabetes mellitus subgroup also saw lower heart failure exacerbation risk with finerenone (56.6% vs 74%; HR, 0.59; 95% CI, 0.5-0.69; 

Despite the strength of these data, this study is solely hypothesis-generating. Desai and colleagues encourage further research, including head-to-head randomized controlled trials of finerenone versus spironolactone in HFpEF, to inform the debate over its safe and efficacious use in real-world settings.

“If we’re going to follow the evidence and what the literature would tell us, finerenone would be a primary strategy in those patients with an EF ≥40% if finerenone is not available, or if there are other barriers that might restrict the use of finerenone,” Desai said. “Spironolactone is maybe an option B for a patient on the edges, but for most of our patients, we believe the data – finerenone seems to be the most effective MRA for those patients.”

Editor’s Note: Desai reports disclosures with Amgen, AstraZeneca, Novartis, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, and others.

Almas T, Shelig M, Al-Hindawi A, et al. Steroidal versus non-steroidal mineralocorticoid receptor antagonists in heart failure with preserved ejection fraction: A propensity-matched multi-network nationwide cohort study. European Heart Journal - Quality of Care and Clinical Outcomes. Published online January 30, 2026. 

Pitt B, Kober L, Ponikowski P, et al. Safety and tolerability of the novel non-steroidal mineralocorticoid receptor antagonist BAY 94-8862 in patients with chronic heart failure and mild or moderate chronic kidney disease: a randomized, double-blind trial. Eur Heart J. 2013;34(31):2453-2463. 

McCausland FR, Vaduganathan M, Claggett BL, et al. Finerenone and Kidney Outcomes in Patients With Heart Failure: The FINEARTS-HF Trial. J Am Coll Cardiol. 2025;85(2):159-168. 

Desai discusses his recent observational cohort study indicating finerenone’s substantial reduction of heart failure exacerbation risk in patients with HFpEF.

This segment looks ahead to remaining challenges in FCS diagnosis and access, and to the broader implications of APOC3 inhibition for hypertriglyceridemia management.

Perspectives on Ongoing Unmet Need and the Future of FCS Care

Despite major therapeutic advances, substantial unmet need remains in the diagnosis and management of familial chylomicronemia syndrome (FCS).

In their closing reflections, Nihar R. Desai, MD, and Anthony Giamo, MD, note that many patients first present to hospital-based internists with acute pancreatitis and markedly elevated triglycerides, where distinguishing FCS from multifactorial chylomicronemia can be challenging. They emphasize the importance of early referral to lipid specialists and point to resources such as the National Lipid Association’s directory of lipidologists to facilitate expert evaluation and confirmatory testing.

The experts also highlight real‑world obstacles related to coverage, access, and cost of newly approved APOC3‑targeted therapies. Transitioning from controlled trial settings and modeling exercises to broad clinical impact requires that patients can reliably obtain and continue treatment. In addition, long‑term data on pancreatitis reduction, quality of life, and potential cardiovascular outcomes are still needed, and there is strong interest in head‑to‑head comparisons and expanded indications.

Looking forward, advances in FCS are expected to inform the management of broader populations with severe or mixed hypertriglyceridemia. The mechanistic insights gained from APOC3 inhibition may spur development of additional agents and rational combination strategies targeting triglyceride‑driven disease. The faculty characterize this moment as an inflection point in preventive cardiology and lipidology, in which a historically refractory condition now has effective targeted therapies, and ongoing education, research, and systems‑level efforts will be critical to fully realizing their potential for patients.

Nihar R. Desai, MD, MPH

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