At Kidney Week, there is a call to action on cardio-kidney disease
Click Here to Manage Email Alerts
The kidney community is in a sweet spot with the availability of new and effective therapies that prevent the progression of both diabetic and non-diabetic kidney diseases.
These drugs also reduce the huge burden of cardiovascular disease in patients with chronic kidney disease (an important cause of morbidity and mortality in this patient population).
Thus, following on decades of stagnation, we now have three groups of new agents - glucagon-like peptide 1 (GLP-1) agonists, non-steroidal mineralocorticoid receptor antagonists (nsMRA), and sodium glucose co-transporter 2 (SGLT-2) inhibitors - that have shown in large randomized clinical trials to have, in general, a significant cardio-kidney benefit in the setting of both diabetic and nondiabetic kidney disease.1-9
It is critically important, however, to realize that our work is just beginning. There are currently more than 500,000 patients on hemodialysis in the United States; 41% have a 5-year life expectancy and most have an extremely poor quality of life. Yet, we spend $114 billion of predominantly taxpayer money on all CKD and end-stage kidney disease care (equivalent to one in five of all Medicare dollars).10
Vulnerable populations
In marked contrast to other specialties of medicine, there is an urgency to get the right therapies into the right patients in the right way as soon as possible, so we can reduce CKD progression to end-stage kidney disease along with the cardiovascular complications and cost associated with CKD care. While there is no doubt the clinical science in this area will continue to grow, the greatest challenge for all the stakeholders within the kidney community (patients, industry partners, health professionals and federal agencies) is the rapid implementation and individualization (as needed) of these therapies, particularly in vulnerable populations (African Americans, Hispanics, Native Americans, low socioeconomic strata, rural areas and inner cities). These populations not only need these therapies the most but bear a far greater burden of kidney disease.
What we need is a multipronged approach that involves all the stakeholders above that prioritizes the following:
- education and awareness about kidney disease, both at the level of the patient and the primary care provider;
- a commitment at the level of federal agencies, ACOs, large and small health care organizations, professional organizations and guideline committees to prioritize, through incentives and more, the measurement of a urine albumin-to-creatinine ratio (UACR) and eGFR in patients who could be candidates for these new therapies;
- a commitment from payers of all types (federal or private, national or regional, urban or rural) to create targeted payment plans for these new therapies. Expanding the new global payment plans within the Advancing American Kidney Health initiative to include patients with CKD stage 3 could also jump start the widespread use of these new therapies; and
- a potential central role for pharmacists in ensuring that clinical guidelines are followed and implemented.
The availability of these new therapies also allows us to begin an important discussion about whether we go down a pathway of combination therapy with two or more of the three therapeutic groups vs. algorithms of care where the sequence of agents used depends on the clinical, demographic and biological characteristics of the individual patients.
An opportunity
In summary, the kidney community has an opportunity that we must grab, because this confluence of awareness and excitement in the setting of a vibrant innovation substrate for kidney disease, including the Kidney Health Initiative, the KidneyX Innovation Accelerator and the Advancing American Kidney Health initiative, may not come again for decades.
Above all, we must succeed because if we do not, then our patients will look at the parade of new therapies in other professions and ask, “If not me, then who, and if not now, then when?”
- References:
- 1. Pitt B, et al. N Engl J Med. 2021;doi:10.1056/NEJMoa2110956.
- 2. Brosius FC, et al. N Engl J Med. 2020;doi:10.1056/NEJMoa2022190.
- 3. Jarcho JA. N Engl J Med.2020;doi:10.1056/NEJMe2027915.
- 4. Ingelfinger JR, et al. N Engl J Med.2020;doi:1056/NEJMe2031382.
- 5. Bakris GL, et al. N Engl J Med.2020;doi:10.1056/NEJMoa2025845.
- 6. Perkovic V, et al. N Engl J Med.2019;doi:10.1056/NEJMoa1811744.
- 7. McMurray JJV, et al. N Engl J Med. 2019;doi:10.1056/NEJMoa1911303.
- 8. Ingelfinger JR, et al. N Engl J Med. 2019;doi:10.1056/NEJMe1904740.
- 9. USRDS Annual Data Report: Epidemiology of kidney disease in the United States. NIH, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md. (https://adr.usrds.org/2020).
- 10. Maddux FW. Semin Dial 2020;doi:10.1111/sdi.12849.
- For more information
- Prabir Roy-Chaudhury MD, PhD, FRCP (Edin), is a professor of medicine at the University of North Carolina (UNC) and co-director of the UNC Kidney Center. He can be reached at prabir_roy-chaudhury@med.unc.edu.
Collapse
Read more about
Click Here to Manage Email Alerts