Updates in the Management of Chronic Kidney Disease and Type 2 Diabetes - Episode 9

Early Identification and Management of CKD

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What better testing strategies and newer quality measures can do to improve patient referrals to nephrologists for earlier intervention of chronic kidney disease.

Neil B. Minkoff, MD: Going back to my days in an integrated delivery network, the concept is that nephrologists would complain that they were seeing patients, and if you went back and looked at their chart, their GFR [glomerular filtration rate] was rising and rising, and they were getting the patient referred to them later than they should have. Or there was information in the chart, but it wasn’t being acted on. Do you think these quality measures spur that level of action that was missing 10 years ago?

Eugene Wright Jr., MD: First, the GFRs would be falling, right?

Neil B. Minkoff, MD: Yes, I’m sorry. I was trying to say that the kidney function was decreasing.

Eugene Wright Jr., MD: I’d like to hear what George and Rajiv have to say, but one of the things we’ve traditionally not done in primary care is use a graphic of the GFR decline. We use graphics for everything else, including for blood pressure control, lipids, and temperature. Why do we use a graphic? Because it’s easier to spot a trend than to look at a string of numbers.

Neil B. Minkoff, MD: Right.

Eugene Wright Jr., MD: I would propose that we take these very powerful tools that we have now and start to graph eGFR [estimated glomerular filtration rate] over time, because it makes it more obvious early on when something is going on.

Rajiv Agarwal, MD: Neil, this is an important point. In the system I work in, which is the VA [Department of Veterans Affairs], we have a computerized patient record system, we call it CPRS. For the last 20 years, we’ve been able to graph everything that we want. When I joined the VA a little more than 25 years ago, the director of the renal clinic asked me what laboratory tests we should get for every patient who comes to the renal clinic, and I said urine protein and urine creatinine at every visit in every patient, and that’s what we’ve done. In every patient and every clinic visit, they get this test done.

Gene asked, “Is the burden of the test greater than anything else?” It doesn’t cost you anything to pee, and the test is inexpensive, especially to the VA, where it’s done at cost. We have an incredible amount of information in every patient who’s been seen, and you can act upon it. George said, “When you’ve got 4 g proteinuria and an eGFR of 75 mL/min, you’ve got a lot of kidney disease.” But we can track it over time and make interventions that matter.

Cholesterol and blood pressure are common parlance in our society. Everybody knows what blood pressure and cholesterol are. With UACR [urine albumin-to-creatinine ratio], I would beg to differ. Nobody knows what a UACR is. Most doctors might not know. “What are you talking about, UACR? I’ve never heard of that test. Do you mean CRP [C-reactive protein]?” No, I’m talking about UACR. You can do something about it because this isn’t a test of kidney, but of cardiovascular disease risk. This is a test that nephrologists didn’t discover. The Framingham Heart Study started this in 1984, that if you have protein in the urine, you’re at risk for cardiovascular disease. Framingham is right in your backyard, Neil. We discovered this, and we haven’t put it in the lexicon of the common parlance. A lot of people said, “You know your blood pressure and your cholesterol. What’s your UACR?” It’s as important a test if you have type 2 diabetes.

George L. Bakris, MD: Neil, if you want to get scared about what Rajiv just said, open up the latest issue of Diabetes Care. There’s a beautiful paper in there that has looked at albuminuria measurement, and it’s abysmal. Less than a third of the patients who should have albuminuria measured actually had it measured. It’s a real problem. The National Kidney Foundation has tried in various ways to get this out, but it only seems to be resonating with nephrologists. We published a paper in 2014 in Diabetes Care arguing exactly what Rajiv just said. We looked at all the data and said microalbuminuria has to do with cardiovascular disease and doesn’t have to do with the kidney. We made a strong argument, and the cardiologists took notice, but it’s only been very recently that they’ve really taken notice. Things move slowly in terms of concepts.

The other thing is that when we were writing kidney guidelines in 2004 as to when to refer, I suggested back then that if your GFR is below 60 mL/min, they should be referred to a nephrologist, and…my colleagues said, “That will be impossible. We’ll drown.” So the GFR was 30 mL/min for referral. If you take the number of nephrologists and endocrinologists together, we’re still about 50% less than the number of cardiologists who exist. There’s no way nephrologists can handle this burden. Primary care physicians have asked, “What’s the magic? What are you going to do?” I tell them and they’re underwhelmed by the pedestrian nature of what we’re talking about. They can do that, they just don’t think it’s going to do anything. It’s a problem.

Transcript edited for clarity.