Closing the Gap Between New CKD Therapies and Patients Who Need Them

The biggest gap in kidney care is shifting from a lack of treatments to finding patients early enough to use them and getting new therapies into routine practice, according to 4 experts at the American Society of Nephrology (ASN) Kidney Week meeting.

Why Earlier Detection of Kidney Disease Matters

Chee Kay Cheung, MBChB, PhD, consultant nephrologist and honorary associate professor at University Hospitals of Leicester NHS Trust, said the largest unmet need is therapy that does more than slow progression. For patients with glomerular diseases such as immunoglobulin A (IgA) nephropathy, the goal is to stabilize kidney function, so they never face dialysis or a kidney transplant.

“We really need to think about how we can identify kidney disease much earlier in the disease course, access these new therapies that have a real potential to help us towards that goal of preventing kidney failure in our patients with glomerular diseases,” he said.

Rachael Morton, PhD, professor and director of health economics and health technology assessment at the NHMRC Clinical Trials Centre and faculty of medicine at the University of Sydney, said many people with chronic kidney disease (CKD) do not know they have it.

“I really think the big gap is that we don’t have national targeted CKD screening programs,” said Morton.

She compared the opportunity with screening for bowel cancer, breast cancer, and diabetes, noting that effective medicines now exist to prevent progression to end-stage kidney disease.

“I'm now starting to see a whole range of new therapeutic options for people with chronic kidney disease,” Morton said. “We want to see improved survival, we want to see better quality of life, and now we've got a whole lot of agents to do that.”

Jai Radhakrishnan, MD, MS, professor of medicine and clinical chief of the Division of Nephrology at Columbia University Irving Medical Center, described how many steps come before treatment. CKD is asymptomatic until late, and urine testing for otherwise healthy patients is not in guidelines. Because no biomarkers exist for rare diseases such as IgA nephropathy, patients must also reach a nephrologist who can perform a biopsy.

What Is Slowing Implementation of New Kidney Therapies

Katherine R. Tuttle, MD, FASN, executive director for research at Providence Health Care and professor of medicine at the University of Washington, called the evidence-to-practice gap the biggest one to close. She said progress starts with awareness and detection, followed by policy and practice changes that support treating kidney disease. Real-world data on sodium-glucose cotransporter 2 (SGLT2) inhibitors show the scale of the problem.

“We’re on track for that 17-year gap from evidence to optimal uptake, even for SGLT2 inhibitors,” said Tuttle.

Radhakrishnan said he is watching for whether the estimated glomerular filtration rate slope decline differs from the standard of care or placebo in interim analyses. With many IgA nephropathy drugs emerging, he said questions about combination and sequencing will likely be answered through post hoc analyses or large registry data.

How Precision Approaches Could Guide Kidney Treatment

Tuttle said trials report aggregate results even though both active and placebo groups include responders and nonresponders. Identifying in advance who responds could show which patients do well on a single drug and which need combinations. Biomarkers, big data, and artificial intelligence could help determine who is at highest risk and how to monitor them.

“Who might respond best to what treatment? How do we identify them? How do we monitor them?” she asked. “For me, it's 2 things: implementation and precision; broad and deep.”