Jeffrey Feldman, MD, details the clinical burden of CKD management, and Bertram Pitt, MD, discusses the impact CKD can have on patients at risk for cardiovascular disease.
Ryan Haumschild, PharmD, MS, MBA: As we think about quality of life, I’m going to pivot to one of my clinical experts, Dr Feldman, to discuss the clinical burden of CKD [chronic kidney disease]. Dr Feldman, if you want to bring in some economic thoughts as well, that would be appreciated. How does that impact your patients’ quality of life? What aspects of CKD are most impactful on the patient? How does this burden and change in their quality of life impact their disease progression and their willingness and motivation to stay compliant with therapy?
Jeffrey Feldman, MD: That’s a very complex question. I’m going to break it down and start where Paul left off. I was trained in the 1970s and 1980s as a nephrologist, and our tools were dialysis or transplant. I was fortunate that my mentor favored transplant, so I was never a big dialysis doctor. Then in the 1990s, we heard about chronic kidney disease and chronic kidney programs. I also worked with my cardiology fellows in lipids and things.
Right now, we’re trained to take care of people when they get ill. We don’t do a lot of prevention, as Paul talked about. As part of my lipid hat, we got involved with the AHA [American Heart Association] Life’s Simple 7, which talks about prevention for people in their 20s and 30s with very simple parameters. It would be preventive, especially if you could bring in the social determinants of health, access to care, food, and exercise. As Paul alluded to, there are a lot of places where there’s no safe place to exercise.
We have to get away from chronic care management and get more preventive, find disease early, and control the risk factors so it doesn’t progress. The economic value is tremendous because the [highest] cost of disease is at the end stage. People spend more money at the end of their life than during the middle. It’s part of our ACO [accountable care organization], we know exactly how much money we’re going to spend per patient, so [it’s important to] do the right thing early and work to give people access to care.
I love Dr Agarwal’s hypertension program in the barber shop in the Southeast United States. We also heard [about] a health program for women in beauty shops and nail salons. We know how to do it, but we aren’t doing it. The way to save money is to give people programs that we know work. Some of them aren’t expensive, such as Life’s Simple 7. It talks about health care behaviors, your LDL [low-density lipoprotein], your blood pressure, exercise, and diet. If people develop [CKD] and need the medications, we add them on top of diet, exercise, and lifestyle.
I’ve been around for about 40 years. The first 35 years of my career, I had nothing to offer. I had ACEs [angiotensin-converting enzyme inhibitors], ARBs [angiotensin-receptor blockers], diuretics, and some diabetic medicines. We had cholesterol medicines, which were underutilized. But over the last 5 years, we [gained] tools in our toolbox that are tremendous. [It’s important to] work with lifestyle changes, get patients on board, show what they can do, and look at quality of life. Do they feel better? With our obesity epidemic, probably 60% of my patients are obese. Using these newer GLP-1 RAs [receptor agonists], people lose weight for the first time in their lives. It’s an amazing transition. They look at me and they want to continue it.
As Dr Agarwal said, if you tell people, “You aren’t compliant with your medications. You have to do this, this, and this,” You lose them. But using the tools that Paul and Dr Agarwal suggested and our newer medications, you can engage patients and they’ll stay on the program and they’ll do better. Moving away from chronic disease management to primary prevention, we have to do simple things like lifestyle and Life’s Simple 7.
Ryan Haumschild, PharmD, MS, MBA: Excellent. Thank you, Dr Feldman. I’m hearing a lot that there’s comorbid disease, and early prevention is key to treating these patients. Dr Pitt, as our resident expert not only in cardiovascular disease but also when we think about some of these patients with CKD, what’s the relationship between chronic kidney disease and cardiovascular disease? We know cardiovascular disease is underdiagnosed in this patient population. How can clinicians better recognize patients with CKD who are at high risk for developing cardiovascular disease? How do we create interventions earlier and treat these patients before their disease progresses?
Bertram Pitt, MD: My colleagues have touched on a lot of the aspects. With chronic kidney disease, a lot of discussion has been about end-stage renal disease, dialysis, and transplantation. But along this course, there’s a tremendous increase in risk of heart failure, and heart failure often occurs way before you get to end-stage renal disease. We talked about the burden of the patient and the caregivers once you have chronic renal disease. But once you have concomitant heart failure, there’s added burden, a tremendous risk of hospitalization, outpatient visits, and a tremendous burden on the family. We touched on this earlier when we were talking about diagnosis.
Once you have CKD, a drop in GFR [glomerular filtration rate] to less than 60 mL/min, you have a lot of irreversible changes. But you also have to realize that if you have albuminuria, even with a normal CKD, you also have a risk of heart failure. That’s why it’s so important for people to screen for albuminuria. It just doesn’t happen. It doesn’t happen in diabetes, it happens part of the way. But it’s even worse in hypertension. No one is looking. Less than 1% of people are being screened for albuminuria. Once you see albuminuria, there’s an opportunity to intervene. We have very potent tools to prevent the development of heart failure. Because once this journey starts, it’s a very difficult journey.
Transcript edited for clarity.