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We Have to Do Better for People With Kidney Disease, Say Experts

The care of patients with chronic kidney disease (CKD) must be overhauled, say experts as they outline a list of key priorities designed to improve kidney health across the United States.

The call to action has been published as part of a joint statement, “Shared Viewpoint — Developing the Future of Kidney Care,” by the National Kidney Foundation and OptumLabs, in the Journal of General Internal Medicine.

One key recommendation is to improve the education of primary care clinicians, “beginning in medical school, continuing in residency, fellowship, and on to advanced practice levels; about CKD risk factors, testing, detection, and interventions.”

Another aim is “a future where each person is aware of their kidney health status as well as their blood pressure, cholesterol, and metabolic health,” they add.

“This has been a wild year for patients. We’ve had huge challenges because of kidney disease from COVID-19 and missing care for patients who are just afraid of COVID-19 and haven’t gotten their blood tested, their urine tested, or even seen their physician,” Joseph Vassalotti, MD, lead author and chief medical officer of the National Kidney Foundation, told Medscape Medical News.

“So we have to do better for people with kidney disease in America. They have unacceptable outcomes, the healthcare system doesn’t help them, and identifying these priorities is the first step to a much better future in the kidney community,” he added.

The joint statement points to four overall priorities that, if implemented, could reduce the number of Americans living with CKD, improve patient care, reduce cardiovascular hospitalizations, prevent or delay kidney failure, and contain the $120 billion of public funds spent on kidney disease in the United States each year, say the authors.

The four priorities are:

  • Improve screening, diagnosis, and documentation of kidney disease.

  • Improve engagement with patients and focus on person-centered kidney care.

  • Move Medicare reimbursements upstream leading to earlier interventions.

  • Increase access to evidence-based therapies for patients with CKD.

Improve Screening, Test for Both eGFR and Albuminuria

An estimated 37 million people in the United States have kidney disease, and up to 90% are not aware they have it, according to the joint statement.

Vassalotti noted that kidney disease is often silent: people may feel well or may have symptoms but don’t attribute them to kidney disease. So the first priority is to help people better understand the spectrum of disease and its attendant risks, which includes cardiovascular disease (CVD), worsening renal function, and eventual need for dialysis and transplantation.

To identify more patients at risk for kidney disease earlier, the authors argue that the United States Preventive Services Task Force (USPSTF) needs to update their 2012 recommendation. As the 2012 recommendation stands, the USPSTF essentially advises not to perform mass, or general population, screening for CKD.

“I think that statement is fine, I don’t quibble with it,” Vassalotti noted.

However, practicing clinicians generally interpreted the recommendation as they shouldn’t screen for CKD at all, and that there was not enough evidence to screen even patients with diabetes or hypertension at high risk for CKD, he pointed out.

This, in his opinion, is a major flaw of the USPSTF recommendation because, by definition, patients with diabetes, hypertension, or both are indeed at high risk for kidney failure and absolutely should be screened.

Then there are the tests that are used — and not used — to screen kidney function.

Most patients with diabetes or hypertension likely have their estimated glomerular filtration rate (eGFR) determined each year to assess their kidney function. On the other hand, the urinary albumin-to-creatinine ratio (UACR) is much less frequently used for risk stratification in routine care, Vassalotti pointed out.

This, he feels, is again an oversight, and the joint statement is calling for a simple strategy that would allow clinicians to check the boxes for both tests at the same time so that patients’ kidney lab profiles would include both measures of kidney function.

Finally, adding clinical decision support tools for CKD to electronic medical records “will help identify CKD cases earlier in priority populations and drive improvements in the quality of care patients receive,” say Vassalotti and colleagues.

Empower Patients

To help improve patient engagement and focus on patient-centered kidney care, the authors recommend that clear and simple layperson-centered language is used in all clinician communications related to CKD self-management “to enhance patient understanding and empowerment.”

Assessing which patients are able to use telehealth, and any potential barriers, will further help, as will adoption of home-based testing for CKD or CKD risk factors using self-administered laboratory tests or devices, in the same way people monitor their blood glucose and blood pressure at home.

The authors would also like to see more widespread promotion of home hemodialysis and peritoneal dialysis to optimize CKD self-management.

Earlier Intervention Could Greatly Reduce Costs

Improved CKD population health will limit cardiovascular hospitalization, reduce transitions to more advanced stages, and reduce end-stage kidney disease (ESKD).

“Collectively, these improved outcomes will reduce expenditures. Most patients with CKD will not progress to ESKD,” say the authors.

This would help reduce the $120 billion spent by Medicare in 2018 ($70 billion of which was for the care of CKD not requiring dialysis or transplantation). Commercial health insurance expenditures for CKD are estimated to be around the same, at $70 billion.

Among the recommendations:

  • Develop key performance indicators that further connect early-stage CKD detection with evidenced-based therapeutic interventions, and link performance to clinician reimbursement incentives.

  • Shift federal initiatives and reimbursement strategies earlier in the CKD continuum, focusing on primary prevention of CKD and optimization of risk factors for CKD progression.

  • Integrate new measures, such as the Kidney Health Evaluation for Patients with Diabetes measure, into the Merit-based Incentive Payment System (MIPS) for Medicaid and Medicare quality measure programs and payment models to promote early screening and diagnosis.

Better Access to New Medications

Finally, easier and more affordable access to established and new and emerging therapies for kidney disease — as well as diabetes and heart failure,  both of which often accompany kidney disease — will also improve outcomes.

Even statins remain underused in around a third of the CKD population eligible to receive them, say Vassalotti and coauthors.

Other key drugs are the angiotension-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and sodium-glucose cotransporter-2 (SGLT2) inhibitors, as well as glucagon-like peptide 1 (GLP-1) receptor agonists and a new potassium-sparing diuretic, finerenone (Kerendia, Bayer Healthcare).

Updating existing clinical guidelines to include recent advances in evidence-based treatments for kidney diseases is essential, say the authors.

The ACE inhibitors and ARBs reduce the risk of kidney failure by around 15% to 30%, while the SGLT2 inhibitors reduce the risk of kidney failure by 30% to 45%, said Vassalotti.

“So if patents are going to stop one of their CKD drugs, let’s try not to stop the ACE inhibitor or the ARB. And if they are going to stop one of their diabetes drugs, they should try not to stop the SGLT2 inhibitor because they reduce not only the risk of kidney failure but also the risk of CV hospitalization and death,” Vassalotti explained.

“We want to do several things here: both prevent kidney failure or at least delay it. And when we do that, we are going to reduce CVD risk, and we think we will prolong life and hopefully improve quality of life as well.”

“It’s really an exciting time in nephrology, and I want to reinvigorate it now that we have all these exciting new therapies that we can help to deliver to patients,” he enthused.

J Gen Intern Med. Published online August 30, 2021. Full text

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