OBJECTIVES: The therapeutic landscape for mild-to-moderate chronic kidney disease (CKD) is broadening, but at a cost: renin-angiotensin-aldosterone system inhibitors (RAASi) and mineralocorticoid receptor antagonists (MRA) increase potassium levels, while sodium-glucose co-transporter-2 inhibitors (SGLT2i) lower potassium levels. Physicians can now make treatment decisions for specific patient profiles, consider different risks and benefits when managing CKD, and describe unmet treatment needs. We sought to explore how physicians make decisions for CKD treatments.

METHODS: Physicians in US, UK, France, Germany and The Netherlands treating mild-to-moderate CKD participated via semi-structured interviews. Interviews asked physicians to define mild-to-moderate CKD, prescribe treatments across different patient profiles, consider different risks and benefits when managing CKD, and describe unmet treatment needs. Interviews also included a quantitative preference elicitation task where physicians selected a preferred treatment from hypothetical alternatives.

RESULTS: Physicians consisted of general practitioners (n=11), cardiologists (n=1) and nephrologists (n=5). Definitions of mild-to-moderate CKD varied and participants noted an unmet need for treatments to slow CKD progression (n=8). Most physicians indicated willingness to prescribe RAASi across different patient profiles. SGLT2i were considered for patients with diabetes, hyperkalaemia (potassium 3.5-5.0 mmol/L), or already being treated with RAASi or MRAs. (n=11) considered SGLT2i as a stand-alone treatment. Hesitancy was observed for prescribing MRAs, especially by general practitioners, however MRAs were perscribed for patients with uncontrolled hypertension and patients already being treated with RAASi or SGLT2i.

Key side effects physicians sought to avoid were severe hyperkalaemia (potassium ≥6.0mmol/L), acute kidney injury, and hypotension. Physicians were on average willing to tolerate a 14.4% risk of hyperkalaemia (potassium ≥5.5 mmol/L).

CONCLUSIONS: We highlight the complexity in decision making for mild-to-moderate CKD treatment pathways; physicians have to balance slowing CKD progression with the risk of hyperkalaemia. Definitions and treatment approaches varied among physicians, highlighting non-uniform attitudes and behaviours toward treatment decision making.