VIDEO: Addressing inadequate treatment response in patients with CKD

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I define those folks as people who have markers of kidney dysfunction. And I look at kidney dysfunction both by laboratory markers but also by clinical status. So they would have markers of kidney dysfunction or clinical status indicative of kidney dysfunction despite the optimal therapy being instituted. So the consequences, especially for people for example, who have an uncontrolled blood pressure or uncontrolled edema can be recurrent hospitalizations for high blood pressure or heart failure.

And unfortunately, it can also sometimes be a devastating additional organ involvement like after a stroke or with a heart attack that can be a complication of inadequate control of their progression. I try my best to look for clinical trials that they may be eligible for and fortunately in our current space, we do have more and more options for those clinical trials, especially for people who have an underlying glomerular reason for inadequate response, we do have additional clinical trials available, so I try my best to get them enrolled in that.

And I tell them that the benefit of that type of enrollment, even though there's a usually a 50% chance that they would end up on a placebo, there's still benefit for them because it allows their clinical status, and their laboratory status to be monitored much more carefully in much more standardized way. And that will hopefully generate some positive feedback loop for themselves and for me, and the treating sort of PI of the study that will inevitably yield some benefit in terms of their own kidney protection. I think that's a great question because I think perhaps like thinking about it now, maybe I'm too narrow on how to define inadequate responders.

One is certainly people who are on all optimal therapies that I know of, that I can think of, and I've attempted to introduce them, yet they still have progressions. That is one category of inadequate responders. There's two other categories. One is that there are either socioeconomic barriers or barriers in how I am able to connect with the patient in terms of in ensuring their willingness to initiate some of these treatments. And so some of those people, even though I have offered treatment, may not end up on treatment. That is another category of inadequate responders.

And there I think what I do is be very humble and spend as much time as I possibly can explaining the risks and benefits and don't close the conversation too early. Have the conversation, circle back on it, maybe not the next visit, but the visit after, just to continue to give them my personal opinion as in parallel while building a relationship with them about why I think this is what is best for them and for them individually. And then a third category of inadequate responders maybe someone who has side effects to the treatments that are best optimal. And so for example, although I love SGLT2 inhibitors and they are indicated in many of my patients, sometimes a patient may have a complication like a urinary tract infection.

One of my patients had a reaction that was an unusual form of colitis that was timed with the initiation of SGLT2 inhibitor, may or may not have been related, but certainly that patient felt like it was. And so I had to work with them in terms of were they... First of all, willing to attempt this treatment again? And then second, could I do something? Could I facilitate some sort of care for this side effect that would potentially prevent it when we attempted to re-challenge the patient. And in that case, they were willing to work with me and partner with me and allow me to reach out to their other providers to coordinate a plan of care that could be preventive for their particular side effect and then reintroduce the optimal treatment.