Dr Haumschild drives a conversation regarding CKD treatment in the presence comorbidities such as cardiovascular disease and type 2 diabetes.
Ryan Haumschild, PharmD, MS, MBA: It’s very clear that we’re seeing an increase in chronic kidney disease [CKD], and it’s something that progresses over time from stage 1 to stage 5. And so how do we be more intentional about identifying those populations earlier and create earlier interventions?… And so that gets us started as we think a little bit about what the interplay between CKD is and between cardiovascular disease and type 2 diabetes or metabolic syndrome. Dr Green, I’ll turn to you. How does CKD interact with cardiovascular disease and type 2? Do they compound upon each other? Can CKD exacerbate heart disease and type 2 diabetes or vice versa?...
Jennifer B. Green, MD: Thanks for asking that question. And also thank you for asking it early on in our conversation. We tend to think about these conditions as being separate or individual conditions. In fact, there’s a tremendous amount of overlap, and it’s very common for a given individual to have all these problems, or at least more than 1 of them. And unfortunately, if you have 2 conditions of those that you had mentioned, so type 2 diabetes plus, for example, heart failure or chronic kidney disease, your outcomes are expected to be worse. You will be at greater risk for adverse outcomes than someone who just has a diagnosis of 1 of those conditions. So unfortunately, the risk is compounded when you have more of those conditions. But they’re probably different manifestations of a single underlying degree of metabolic risk that we need to appreciate and really treat as a whole entity…rather than focusing on 1 aspect of these complications and addressing only a portion of the individual’s risk.
Ryan Haumschild, PharmD, MS, MBA: It really plays into almost that cardiovascular renal metabolic syndrome that we hear so much about in CRM [cardio‐renal‐metabolic] and that interplay with CKD. And one of the things you talked about is a lot of these patients might have more than 1 comorbidity. And when they do, it poses more of a significant risk to their health but also the cost of care. And so, Dr Cohn, as we bring in your expertise, we know that CKD and patients with multiple comorbidities pose an increased economic burden, especially when those patients progress through CKD, if not identified early by their primary care physician…. Could you characterize some of the economic costs, whether it’s directed [at] the comorbidities or CKD directly? What are the key cost drivers? And is this affected by comorbidities? They drive the cost even higher. And maybe lastly, how do you see the burden of cost or the economic burden changing over time?
Ken Cohen, MD: Just as a frame of reference for the total cost in 2019, Medicare spent over $89 billion associated with managing chronic kidney disease, and it falls into 2 broad categories. Obviously, renal replacement therapy is very expensive, but that’s a very smaller subset of patients with CKD. A lot of the spend is in earlier stages of CKD and really falls into 2 different buckets. One is cardiovascular, so a myocardial infarction, stroke, and admission for congestive heart failure are all very significantly elevated in the CKD population relative to non-CKD. The others are specific complications of the CKD itself, and those include things like hyperkalemia. Crashing into dialysis is a very expensive way of entering renal replacement therapy for those who haven’t been identified in advance. So those are some of the major cost drivers. There are also significant disease comorbidities where diabetes, for example, has a high prevalence of neuropathy. So, too, [with] CKD. You put those two together, and advanced neuropathy winds up with chronic peripheral leg disease, diabetic wound infections, peripheral arterial disease. All of those are major cost drivers. And as you progress through stages of CKD, the cost increases. So for example, the cost of managing CKD [stages] 4 and 5 is about 50% higher than managing 2 and 3. So as [the disease] progresses, costs rise. So all [of this] paints a gloomy picture for what we spend on CKD management.
Ryan Haumschild, PharmD, MS, MBA: I appreciate you characterizing the changes over time because I think a lot of times as providers, we know a patient [is] deteriorating, but also as a payer, if we don’t get ahead of this, if we don’t invest in identifying these patients early and stop that progression of disease, there could be greater costs on the horizon. And really, as we evaluate that, looking at the total cost of care, whether it be dialysis in more advanced CKD or whether it’s earlier on where we have cardiovascular complications that make disease more difficult to treat. And so how do we evaluate that whole patient, make sure we’re developing a plan not just for CKD, not just for cardiovascular, but the interplay between them? As we transition, it’s really important, as we talk about cost control and early identification, to make sure that patients are being seen by the right provider. And I think sometimes, traditionally we might think that’s only going to be a nephrologist. But really, a lot of times these patients…whether it’s serum creatinine or the albumin, it really happens in the primary care or the outpatient environment. And so, Dr Anderson, I know that you have a lot of familiarity of courting care for a lot of patients. And so as we talk about [patients with] CKD, maybe you can help characterize for us who really takes care of a [patient with] CKD. Is it the hospitalist? Is it the primary care physician, cardiologist, nephrologist, endocrinologist? And who ideally should coordinate care? And what are some of those best practices that we can share with our viewing audience?
John E. Anderson, MD:I think the simple answer to your question is every one of you listed. Right? But since we know that diabetes is the No. 1 cause of progression of chronic kidney disease, the vast majority of type 2 diabetes in the United States, 90%-plus is taken care of by primary care providers and clinicians. And that means physicians, nurse practitioners, [and] physician assistants. So we really have the opportunity to be on the front line of managing these people. And we have a lot of things in primary care that we’re responsible for. Cardio-renal-metabolic is probably the chief of the things that we need to be doing. So we need to be screening these patients. We do lipid panels once a year. We do basic metabolic panels once a year. So we’re pretty good…. What we’ve not been good at is doing uACR [urine albumin-creatinine ratio] and screening for albuminuria. And that’s probably a legacy of “so what?” For years we’d have somebody on maximum RAAS [renin-angiotensin-aldosterone system] inhibition, blood pressure at target, trying to control their diabetes, telling them to not take anti-inflammatories, and that type of thing. But we really had nothing else to offer them until the past few years. Now it is much more imperative that we do both the renal function as well as your uACR. That’s the urine albumin creatinine ratio because frequently microalbuminuria will precede a decrease in kidney function. And to your point, trying to identify these people early.... Anybody who has a touchpoint with these patients does not get to abdicate responsibility for their care. And so for many years: Here’s my silo, and here’s when I got to stay in it, and here’s the cardiology silo, and here’s the nephrology silo, and here’s the endocrinology silo. We really can’t do that anymore because there is so much interplay across these disease states that anybody seeing that individual patient in the office needs to say, “What are we not doing to maximize care?”
Ryan Haumschild, PharmD, MS, MBA: It’s a great call out…. We put a lot on our primary care providers, but at the same time, this is really part of that core evaluation. And so sometimes a lot of the labs might be ordered, but uACR might be [an] additional lab that can be ordered that could provide better earlier detection as we’re managing the patient as a whole. And I think that’s a really great comment. And I think hopefully we’re creating awareness here as we’re working with our payers and our primary care provider colleagues that are watching it…. I think that’s a great way to go about it.
Transcript is AI-generated and edited for clarity and readability.