Diabetes mellitus is a real global health problem. The estimated global population of adults with diabetes was 588.7 million in 2024, and the International Diabetes Federation (IDF) in the 11th edition of its Diabetes Atlas has projected that by the year 2050, about 852.5 million adults aged 20–79 years around the world will be living with diabetes mellitus.¹ Among IDF regions, the African (AFR) and Middle East and North Africa (MENA) regions are projected to experience the largest relative increases in the number of people with diabetes. Morocco is one of the countries of the IDF MENA region and accounted for 9.7% of diabetes in adults in 2021.² The increase in the prevalence of diabetes has been paralleled by an increase in the occurrence of its chronic complications, such as diabetic kidney disease (DKD). In 2011, it was estimated that diabetes was one of the main causes of chronic kidney disease (CKD) in Morocco.³

Diabetic kidney disease is the leading cause of CKD as well as end-stage renal disease (ESRD)⁴ and contributes considerably to the additional healthcare costs of the management of people with diabetes.⁵ Therefore, early diagnosis and treatment of DKD are critical to prevent kidney disease progression and other complications of diabetes.⁶ The detection of a positive albuminuria identifies the early stages of DKD,⁶ but screening relies on a dual assessment of urinary albumin (using a spot urinary albumin-to-creatinine ratio [UACR]) and estimated glomerular filtration rate (eGFR).⁷

For most people, DKD is asymptomatic and is often diagnosed through routine screening.⁸ Annual DKD screening is recommended by both the American Diabetes Association (ADA) and Kidney Disease Improving Global Outcomes (KDIGO) guidelines,^9,10 and should start at diagnosis of type 2 diabetes and 5 years after diagnosis of type 1 diabetes.^9,10 Based on these recommendations, DKD is diagnosed in the case of persistently positive albuminuria (≥ 30 mg/g) and/or persistently reduced eGFR (˂ 60 mL/min/1.73 m²) for more than 3 months.^9,10

As most patients with diabetes are managed in primary care,¹¹ primary care providers play an important role in the early detection of DKD.

The role of primary practitioners is firstly, to make a timely diagnosis of DKD through early screening of patients with diabetes and secondly, to delay the progression of DKD through efficacious glycaemic and blood pressure control, Renin-Angiotensin system (RAAS) blockade and SGLT2 inhibition in addition to health promotion and comorbidities management.¹²

However, despite international guidelines for screening and managing DKD, early detection and treatment of DKD in primary care settings is not performed optimally in routine clinical settings.^13,14

A gap between ideal and actual care may be because of multiple factors, including a lack of knowledge about the disease itself, the fear of frightening patients with the announcement of CKD diagnosis, high workload or unfamiliarity with current guidelines.^6,7

Therefore, it is important to enhance the effectiveness of the management of patients with diabetes and the prevention of the development of complications.¹⁵

As primary care is usually the first point of contact for most patients with early-stage CKD,¹⁶ assessing the degree of adherence by the primary healthcare physicians to current guidelines that promote early detection, prevention and treatment of DKD is recommended.

This study evaluated the knowledge level of Moroccan primary healthcare providers in the region of Marrakesh about DKD screening, management and referral guidelines, and determined its associated factors.

Our study population was young, with 67% of participants under 50 years of age, the majority were female, and 57% had less than 10 years of experience. Similarly, in a study conducted in Saudi Arabia evaluating clinical practices of primary care providers in DKD, the mean age of the participants was 35 years with a mean experience length of 7 years, but the proportion of male physicians was higher than female physicians (59%).¹⁵

Regarding screening for DKD, our findings have indeed revealed that more than half of the participants correctly identified that a positive albuminuria and reduced GFR were key indicators of DKD.

Compared to our results, an online survey of the proficiency of primary healthcare physicians in managing diabetes-related CKD showed that 52.4% of the participants were uncertain regarding their knowledge of the criteria for the diagnosis of DKD.¹⁸

Most of our participants reported that the ideal timing for first screening of DKD was at the time of diagnosis of type 2 diabetes, and that, essentially, albuminuria (97%) and, to a lesser extent, the GFR (51%) should be annually screened. However, our participants presented insufficient knowledge of the optimal timing for screening in patients with type 1 diabetes and the ideal test to use for screening for albuminuria. In a cross-sectional survey conducted among 160 Canadian physicians, including 60 general practitioners, the timing of CKD screening with patients in relation to type 2 diabetes diagnosis occurred for most physicians at diagnosis of type 2 diabetes (58.1%), using eGFR (100%) and UACR (96.8%).¹⁹ In the Saudi study, good knowledge was reported in terms of annual screening (77.4%), timely start of screening of DKD in patients with type 1 (52.1%) and type 2 (75.6%) diabetes and the use of UACR as a screening tool for DKD (85.5%).¹⁵

In our study, good scores were also reported about first-line recommended medications, but low scores were noted about the use of novel treatment (SGLT2i) and the timing of referral to a nephrologist. In a study of adult primary care patients with DKD, 80.3% had a care gap in SGLT2i prescription, and 42% had a care gap in RAASi prescription. These care gaps for SGLT2i and RAASi were especially observed in patients with DKD with well-controlled diabetes and blood pressure, suggesting failure to recognise DKD as an independent indication for these medications.²⁰ On the contrary, the Saudi study showed high rates of prescription of ACE inhibitors (82.1%) and empagliflozin (73.9%) in addition to a good knowledge of indications of referral to a nephrologist (80.8%).¹⁵ In this Saudi study, higher levels of adherence to the guidelines were associated with the physicians’ education level, access to clinical guidelines and receipt of relevant training.¹⁵

Overall, the majority of our participants (61%) showed high levels of adherence to DKD guidelines, but our results also reflected varying degrees of knowledge across different aspects of DKD management. Our findings also revealed that higher levels of adherence to the guidelines were observed among physicians who received training in diabetes management. This training can be facilitated by setting up primary care kidney disease management programmes. Therefore, a multifactorial approach is necessary based on collaborative efforts to optimise the knowledge level of primary care providers in dealing with DKD.²¹ This lack of DKD knowledge among primary care providers may be one of the causes of delay in CKD identification and treatment, and may be because of many factors, such as the complexity and continuous evolution of the guidelines²⁰ and the absence of communication between primary healthcare and nephrologists.²²

The strengths of this study were that it provided an in-depth analysis of the knowledge level about DKD in Moroccan primary healthcare providers. However, there were some limitations. This study was limited by the small number of participants, its cross-sectional nature, and its reliance on self-reported data rather than a real-time evaluation of practices at primary care centres. Despite these limitations, we were able to identify shortcomings in the management of patients with DKD by general practitioners, which is relevant to running a comprehensive healthcare programme centred around DKD. The results of our study demonstrated the importance of continuous education and can guide the development of national programmes of training of primary healthcare providers in DKD in order to improve guideline compliance.

This study highlighted unmet needs for care and management of DKD patients at the primary care level. It is well-known that in order to ensure the success of any renal healthcare intervention, it is imperative to effectively involve general practitioners using a well-structured approach. Such an approach will need proper training and the implementation of effective primary care disease programmes.