Updates in the Management of Chronic Kidney Disease and Type 2 Diabetes - Episode 1

Characteristics of Chronic Kidney Disease

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Drs Rajiv Agarwal and Eugene Wright Jr. highlight risk factors associated with chronic kidney disease and react to concerns surrounding the assessment and treatment of patients.

Neil B. Minkoff, MD: Hello, and welcome to this AJMC® Peer Exchange program titled, “Updates in the Management of Chronic Kidney Disease and Type 2 Diabetes.” I’m Dr Neil Minkoff, the chief medical officer of Coeus Healthcare and Consulting.

Joining me today for this discussion are my colleagues, Dr Rajiv Agarwal, professor of medicine at Indiana University; Dr Eugene Wright, a consulting associate in the Department of Medicine and the Department of Family Medicine and Community Health at Duke University; and Dr George Bakris, professor of medicine and the director of the Comprehensive Hypertension Center at the University of Chicago.

Today, our panel of experts will be discussing the complexities of chronic kidney disease [CKD] and type 2 diabetes, review the available treatment options, and explore some of the clinical and payer considerations of new and emerging treatments. With that, let’s begin.

To start, let’s make sure that everybody paying attention and listening are all on the same page and we’re all grounded. I was hoping we could do an overview of how we look at the staging of disease and the burden of CKD in patients with diabetes. Dr Agarwal, could you start us with that, please?

Rajiv Agarwal, MD: Sure. Thanks, Neil. The staging of kidney disease is mostly done by measurement of eGFR [estimated glomerular filtration rate]. It’s an estimate of kidney function. Most people just look at eGFR to determine the stage of kidney disease. It’s divided into various stages: 15 to 30 mL/min is stage 4, less than 15 mL/min is stage 5, 30 to 60 mL/min is stage 3, and so on.

But that’s an incomplete assessment. You have to have albuminuria, or what we measure as UACR [urine albumin-to-creatinine ratio], to have a better assessment of kidney function. What we call less than 30 mg/g is normal albuminuria, 30 to 299 mg/g is moderate albuminuria, and more than 300 mg/g is very high albuminuria. When we combine these 2, we can stage kidney disease more appropriately and estimate the burden more accurately across the board. Approximately 8% of the United States population has CKD, which makes them at a high risk for both cardiovascular disease and progression to end-stage kidney disease.

Neil B. Minkoff, MD: When you’re looking at these patients or starting to worry about which patients have CKD, there are different things that we talk about, whether it’s vascular disease or cystic congenital disease. Dr Wright, could you talk a little about the different patient characteristics and what you’re looking for in your patient population that you worry about in terms of CKD and type 2 diabetes?

Eugene Wright Jr., MD: Thanks, Neil. There are a couple of things that are common across the board in patients with CKD and type 2 diabetes. Older age seems to increase the risk for CKD. CKD is slightly more common in women than men. However, whatever advantage men have will be lost, because for every 2 women who develop end-stage kidney disease, 3 men’s kidneys fail. Comorbid conditions, such as hypertension and diabetes, are the primary drivers for CKD. Heart disease and obesity seem to carry some additional risk modification to that. In special populations, such as Native Americans, African Americans, and Hispanics, there are higher rates of hypertension and diabetes, which increases their risk for chronic kidney disease.

Transcript edited for clarity.