Population Health Management of Chronic Kidney Disease (CKD) - Episode 1

Getting to Know CKD

Jeffrey Feldman, MD, and Rajiv Agarwal, MD, MS, provide an overview of chronic kidney disease (CKD) and its prevalence.

Ryan Haumschild, PharmD, MS, MBA: Hello, and welcome to this AJMC® Peer Exchange® Program titled, Population Health Management of Chronic Kidney Disease. I am Dr. Ryan Haumschild, director of pharmacy at Emory Healthcare, and the Winship Cancer Institute. Joining me today for this virtual discussion are my colleagues: Dr. Jeffrey Feldman, nephrologist in the Atlantic Health System; Dr. Rajiv Agarwald, Professor of Medicine at Indiana University School of Medicine; Dr. Bertram Pitt, cardiologist and professor of internal medicine at the University of Michigan; and Paul Sapia, population health strategy principle at Humana. This panel discussion adds to the conversation from our previous AJMC® Peer Exchange® discussing the implications of chronic kidney disease in type 2 diabetes. Today, our panel of experts will discuss the population health burden of chronic kidney disease, explore the relationship between chronic kidney disease and cardiovascular disease, and lastly review unmet needs and additional considerations in the treatment of chronic kidney disease. Thank you, and let’s begin.

Let’s first start talking about the population health burden of chronic kidney disease. I want us to describe the difference between the population health burden and then the economic burden of this disease. As we get started, I’m going to pivot to Dr. Feldman. Dr. Feldman, what are the patient characteristics associated with chronic kidney disease? As in age, gender, race, comorbidities. Give us a little bit of context there as you’re describing the patient population.

Jeffrey Feldman, MD: Good morning, everybody and thank you for inviting me to this distinguished panel. I've been in practice for many years, and over the last several years, the burden has increased in chronic kidney disease. It does not know any age, gender, race, ethnicity. It crosses various population types. It doesn’t care about COVID-19 or politics or anything like that. As I’m an adult pathologist, I do inherit a few pediatric patients, but most of our patients are in their early 20s and span up to 90s. I’ve had patients who come to me with chronic kidney disease with hypertension and, as Dr. Agarwal will hopefully get into and we’ll discuss, even though we have moderate EHR [electronic health record], the patients’ never had a urine analysis. If they did, it was many years ago. We see significant numbers in elderly people and that pretense systemic disease like chronic chromium nephritis or multi systemic disease with vasculitis or myeloma, but the predominance of patients are really patients with the comorbidities of metabolic syndrome, cardiometabolic syndrome with diabetes, hypertension, dyslipidemia, and atrial fibrillation. As they age, they develop worsening chronic kidney disease. Again, this occurs all across the population, race, and ethnicity and age, and it’s more of a problem in our aging population. It gets older, particularly with the increasing rate of diabetes. Right now, between the ages of 21 and 75, there’s about 35 million diabetics. Most of them are type 2. A significant amount have obesity with hypertension. Heart failure is big now, with over 6 million patients, and chronic kidney disease appears to have about 37 or 38 million adult patients. That’s where we stand currently, and we need better, earlier detection and treatment as we’ll discuss hopefully later on.

Ryan Haumschild, PharmD, MS, MBA: Thanks for giving that great overview because I think it’s so important for people to understand the characteristics and how CKD really affects all, especially those with comorbid disease. As we talk about prevalence I want to defer to my expert, Dr. Agarwal, to really give us an overview. What is the incidence and prevalence of CKD in the United States population? If you could, please talk about what the estimated prevalence by stage is.

Rajiv Agarwal, MD, MS: That’s a great question. I’m going to cite the Centers for Disease Control that has done a lot of work in this area. The statistic that is usually cited is more than 1 in 7 Americans have chronic kidney disease. That is 15% of the US adult population, or 37 million people, that are estimated to have CKD. What is surprising is that as many as 9 out of 10 adults with CKD do not know that they have chronic kidney disease. Even if you are talking about stage 4 and 5 kidney disease, about 2 out of 5 are with severe CKD and do not know, which is surprising. When people come to me, they say, “How do you know I have kidney disease? I don't have any problems urinating. I don't have any problems with any blood in my urine.” Many people don't recognize that it is the detection of albuminuria, or low EGFR, that is responsible for making a diagnosis. For the majority of the patients, you can have polycystic kidney disease in the absence of albuminuria and not just kidney disease, or you could have other special kinds of kidney disease. The majority of the people will have either albuminuria or low EGFR, or the combination of the 2, which will define CKD. If you look at the data from the National Health and Nutrition Examination survey, NHANES, and analyze the prevalence by stage, most patients have albuminuria as the defining reason for their kidney disease. This is especially true in people with type 2 diabetes. Stage 3 kidney disease would be a bulk of the kidney disease that comes to medical attention because very few people get their urine even when they have diabetes. Stage 4 kidney disease is < 0.5%, and there are 600,000 or so patients who are on dialysis. They would be end-stage kidney failure and are undergoing dialysis or have received kidney transplant. That’s the burden. Normally, there are 750 million people with chronic kidney disease. If you look at the US prevalence, it is 37 million. You have < 5% of the kidney disease patients in the United States and 95% outside the United States.

Ryan Haumschild, PharmD, MS, MBA: That’s a great overview. It’s a reminder of the impact of this disease on a lot of patient populations. I like how you stratify by the different stages because I think it’s helpful. There are different needs based on those different stages in which patients fall.

Transcript edited for clarity.