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Goals of Therapy for Patients Diagnosed with CKD


Dr Nicholas highlights key objectives in developing CKD treatment strategies.

Ryan Haumschild, PharmD, MS, MBA: So now let’s explore the treatment landscape for CKD [chronic kidney disease] a little bit further. What are the guidelines and kind of the decision-making around CKD approaches to treatment? How do we optimize the disease state alongside some of the coexisting conditions that we spoke about? So as we get started, Dr Nicholas, I want to come back to you. What are some of the goals of therapy for a patient who’s been diagnosed with CKD? What are the strategies you use to help patients achieve these goals? And how would you say goals differ from [those of] a patient who’s also has type 2 diabetes and CKD or someone who has cardiovascular disease and CKD?

Susanne B. Nicholas, MD, MPH, PhD: I’ll begin with saying that in terms of managing chronic kidney disease, we look at the mechanisms that have led to chronic kidney disease. One that we’ve talked about that is high up on the list is diabetes. So for several years now, the standard of care has been focused on optimizing diabetes control, optimizing hypertension, or high blood pressure control, and also the use of renin angiotensin system blockers, drugs that we’ve been familiar with now for more than 20 years, angiotensin-converting enzyme inhibitors, or ACE inhibitors, or angiotensin receptor blockers, [or] ARBs. Those have been the standard of care now for many years. More recently, we’ve been very fortunate in having identified newer therapies that have been shown to provide both kidney as well as cardiac protection. And these medications you mentioned, SGLT2 inhibitors, for example, they have been initiated in patients with diabetes, patients who don’t have diabetes, but on top of standard of care. So on top of the use of ACE inhibitors and angiotensin receptor blockers, we now have access to lifesaving therapies. And in fact, when I talk about lifesaving, I really mean that. You know, we’ve heard about the fact that having diabetes in the patient [who] has chronic kidney disease results in premature mortality. A faster decline in kidney function. And what if…these SGLT2 inhibitors can actually overcome that premature mortality by about 15 years. So if you are an individual and you are looking at your curve of kidney function decline and you see that within 15 years you’re heading toward dialysis, and you can initiate these therapies and actually save that many years, that’s really huge. And that’s really where we are today. It’s a new era and it’s something that we’re all very happy about, regardless of whether you’re nephrologists, endocrinologists, [or] primary care physicians, because we have something that we can offer our patients that we didn’t have previously that has both cardiac as well as kidney protection…. So this is a wonderful time for providers, but it’s an even better time for our patients.

Ryan Haumschild, PharmD, MS, MBA: You’re giving me this excitement because it is all about the patient and how we delay that disease progression, providing some of these efficacious products and how we approach and screen these patients so we can get them started on something that will delay the disease. And when you think about it, there are different types of [patients with] CKD. There are those with preexisting conditions, and there are those with CKD as a whole. But there are maybe different treatment approaches, or maybe there are different outcomes depending [on] whether a patient has comorbid existing conditions such as cardiovascular disease or type 2 diabetes. And so, Dr Green, I’d love to hear your thoughts…. What patient outcomes are common [in] patients with CKD and preexisting conditions? And as you approach these patients from a therapeutic management perspective, what would be the differences of treating someone who, let’s say, has type 2 diabetes vs someone who just has CKD alone? And what is your thought process as a clinician when you’re managing that patient?

Jennifer B. Green, MD: That’s an interesting and important question. One of the things that I think is important to keep in mind is that when you look at the progression of chronic kidney disease over time, the risk and presence of cardiovascular damage and complications and events really progress along the same timeline. And so, with moderate CKD, it’s not uncommon for patients to also have a diagnosis of heart failure and/or the development of coronary artery disease or ischemic changes in the heart, and then later progressing to an increased risk of other cardiovascular events, including cardiovascular or cardiac arrhythmias. So these are almost one and the same process and not necessarily separate complications, although that’s how we handle them. And I would also point out that the cardiovascular risk that is associated with advanced chronic kidney disease is such that many people with advanced chronic kidney disease will in fact die of a cardiovascular event before they ever need dialysis. So dialysis is not the only outcome that we need to strive to prevent. The cardiovascular risk is serious when we think about people with diabetes who have kidney disease. Of course, those people—because they have that complication—also very commonly also have diabetic retinopathy. They may have peripheral neuropathy, they may have peripheral vascular disease, they may have had foot ulcers. They just tend to have a higher risk of complications throughout the body, affecting multiple systems. So if a person with diabetes has chronic kidney disease, make sure they’re seeing the eye doctor so that any retinopathy that they have can be identified and treated early. And then from a diabetes management perspective…if a person with diabetes has worsening of their kidney function, particularly if it’s quite advanced, it becomes more difficult to manage their hypoglycemia safely. They’re at increased risk, for example, of hypoglycemia from sulfonylureas or insulin therapy. They may have more [or] other adverse effects from some of the medications that we use. So we need to be very cognizant of worsening of kidney function, which…unfortunately can happen very suddenly in people with diabetes, and respond appropriately so that the medicines that we’re using for glucose control are used safely and effectively.

Ryan Haumschild, PharmD, MS, MBA: I like that overview of the continuum of care. And it’s not just the CKD, but it’s these other coexisting conditions.

Transcript is AI-generated and edited for clarity and readability.

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