​Background: Diabetic kidney disease (DKD), the leading cause of end-stage kidney disease (ESKD), is associated with excess mortality in patients with diabetes mellitus (DM). Narrowing the implementation gap by embracing emerging therapies is quintessential for improving patient outcomes in DKD. In our study we evaluated the gaps in care of assessment of proteinuria in DKD as well as usage of disease-modifying therapies.

Methods: This observational cohort study included adult patients attending renal clinic (Jan 2019 – Dec 2019) at a tertiary academic health center with a diagnosis of DKD (Stage 1 – 5). Exclusions included Type 1 DM, solid organ transplants and ESKD. The first available nephrology clinic visit was considered as an index visit. Eligible patients were assessed for DKD severity based on the estimated glomerular filtration rate and presence of proteinuria. Conformity to treatment was assessed based on use of renin angiotensin system inhibitors (RASi), mineralocorticoid antagonists (MRA) and SGLT2 inhibitors (SGLT2i). Informatics approaches extracted all clinical and laboratory information. Chi-square tests were used for comparison across groups.

Results: 1,330 patients whose serum creatinine measurements were available were included in the study of which 70% had CKD Stage 3 or better and 30% had CKD Stage 4/5. Cohort was 52% male, 54% white, 50% of them between ages of 60-75, and Medicare as a primary payor in 60%. 711/1,330 (54%) had presence of proteinuria; it was 61% in CKD 4/5. 917/1,330 (69%) had verifiable prescription information. Of those patients, 72.5% were on insulin. Usage of DKD modifying therapy was 8% for SGLT2i, 76% for RASi and 22% for MRA agents. Usage of these agents was higher in presence

of proteinuria [SGLT2i 10% vs 6% (p=0.018); RASi 81% vs 69% (p<0.0001); MRA 25% vs 19% (p=0.0515)]. Medication usage was lower in CKD 4/5 compared to other stages [SGLT2i 2% vs 11% (p<0.0001); RASi 70% vs 78% (p=0.0212); MRA 18% vs

24% (p=0.065).

Conclusions: By informatics based approach we demonstrate gaps in care of evaluation and treatment of DKD in a tertiary referral center. Both proteinuria and CKD stage influence usage of necessary therapies. Adoption of clinical pathways may narrow

implementation gap in DKD management, and allow in improving patient outcomes.