Gaps in Guideline-Concordant Care in Diabetic Kidney Disease: A Real-World Analysis of Screening, Treatment, and Associated Factors.

Background: Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease and end-stage renal disease worldwide. Despite robust evidence-based guidelines, real-world adherence to recommended preventive care remains inadequate. Most prior evaluations have focused on individual care components rather than comprehensive composite care delivery. Methods: A retrospective cross-sectional study of 1010 adult patients with diabetes attending outpatient clinics at King Abdulaziz Medical City, Ministry of National Guard Health Affairs (MNGHA), Jeddah, Saudi Arabia. Full guideline-concordant care (GCC) was defined as composite completion of HbA1c monitoring, albuminuria screening using the urine albumin-to-creatinine ratio (ACR), and renin-angiotensin-aldosterone system inhibitor (RAASi) use among patients with detected albuminuria. Multivariable logistic regression (n = 1007) identified independent predictors of full GCC. Results: Only 22.7% (95% CI: 20.1-25.3%) of patients achieved full GCC. Partial care was the most common pattern (46.2%), followed by no care (20.7%) and near-complete care (10.4%). HbA1c testing was performed in 55.0% and albuminuria screening in 49.3% of patients. Among those with detected albuminuria, RAASi therapy was prescribed in 78.9%. Primary care management (OR 4.79, 95% CI 3.45-6.66; p < 0.001) and hypertension (OR 2.00, 95% CI 1.33-3.00; p = 0.001) were independently associated with full GCC. Age, gender, kidney function, and cardiac disease were not significant predictors. Conclusions: Substantial gaps exist in guideline-recommended DKD care, driven primarily by screening deficiencies rather than treatment failures. Care delivery is influenced more by healthcare setting than by patient characteristics, highlighting the need for system-level interventions targeting detection infrastructure across all care settings.