Collaboration Strategies & Early Detection of CKD in T2D

Announcer:
You’re listening to Diabetes Discourse on ReachMD. This episode is sponsored by Renalytix. Here’s your host, Dr. Charles Turck.

Dr. Turck:
Welcome to Diabetes Discourse on ReachMD. I’m Dr. Charles Turck, and joining me today to share collaborative strategies toward early detection of chronic kidney disease in patients with type 2 diabetes, are Drs. Marina Basina and Eugene Wright. Dr. Basina is a Clinical Professor of Medicine in the Division of Endocrinology, Gerontology and Metabolism at Stanford University Medical Center. Dr. Basina, welcome to the program.

Dr. Basina:
Thank you very much for inviting me to participate.

Dr. Turck:
Dr. Wright is the Medical Director for Performance Improvement at the Charlotte Area Health Education Center. He is also a Consulting Associate in the Department of Community and Family Medicine and in the Department of Medicine at Duke University Medical Center. Dr. Wright, thank you for speaking with us today.

Dr. Wright:
Thank you for having me, Charles. 

Dr. Turck:
So let’s just dive right in. Starting with you, Dr. Wright, can you tell us why detecting chronic kidney disease in patients with type 2 diabetes early on is so important?

Dr. Wright:
It’s a great question. First, it’s common. Chronic kidney disease occurs in approximately 40 percent of patients with type 2 diabetes. Second, chronic kidney disease in type 2 diabetes is underrecognized. The awareness detection and drug therapy in type 2 and chronic kidney disease, with the ADD-CKD study, conducted in primary care practices across the United States between June of 2011 and February of 2012, found that among over 5,000 adult patients with chronic kidney disease and type 2 diabetes, only 12 percent were diagnosed. This means that 88 percent were undiagnosed with CKD by their primary care providers, and this study was based on an electronic health record survey. Third, the complications are severe. Chronic kidney disease associated with type 2 diabetes is a risk accelerator. The risk of cardiovascular death is three times that of patients with type 2 diabetes alone. And then finally, treatment matters and can change the progression of chronic kidney disease to end-stage kidney disease and cardiovascular death.

Dr. Turck:
With that background in mind, Dr. Basina, what do you initially consider when evaluating these patients?

Dr. Basina:
Thank you for the question. When we’re evaluating this patient we need to keep in mind that kidney disease, diagnosed usually late in the course of the disease. Kidney disease, and diabetes, type 1 or type 2 diabetes, is silent until in advanced stages. And that is why it’s critically important to screen and detect disease early, to be able to introduce interventions early for prevention in the early stages for prevention of progression. This is an opportunity for improvement because rates of screening are quite low in the United States, and again, condition usually goes years before it’s diagnosed. The tools that we currently have for assessment of kidney disease, which includes urinary microalbumin to creatinine ratio, and estimated glomerular filtration rate, are the markers that recommended to be checked at the regular intervals by “Kidney Disease: Improving Global Outcome Guidelines,” are the markers that when detected abnormal the kidney damage already happened. We would like to develop the tools and have the tools available easily in clinical practice, to be able to detect this damage or pre-damage before it actually happens. Over the past decade, a significant number of studies have been done to identify early biomarkers that are associated with diabetes nephropathy, but we don’t have a single tool, how to incorporate those biomarkers in our clinical practice, and this is still in the stage of the research. That is why American Diabetes Association is partnering with diagnostic company, Renalytix, to develop a diabetes kidney care pathway, and model to encourage early detection and to improve treatment and reduce risk of progression to end stage kidney disease.

Dr. Turck:
Coming back to you, Dr. Wright, let’s focus on the patient. What are some education strategies you recommend, to help them better recognize the symptoms of chronic kidney disease?

Dr. Wright:
Well, since there are no symptoms early on, this speaks to the need for early screening and early detection, and why that’s so critical. For patients, I try emphasizing that you don’t have to be sick to get better. And that what we’re really seeking to do is to prevent or significantly delay complications, such as death and dialysis, and to improve their quality of life.

Dr. Turck:
For those just tuning in, you’re listening to Diabetes Discourse on ReachMD. I’m Dr. Charles Turck, and today I’m speaking with Dr. Marina Basina and Dr. Eugene Wright about detecting chronic kidney disease in patients with type 2 diabetes.

Now if we turn our attention to multidisciplinary care, Dr. Wright, how do collaborative care teams play a role in the early detection of chronic kidney disease?

Dr. Wright:
It has been shown that a collaborative, team-based approach yields better results, as far as early detection, management and treatment of early chronic kidney disease, and the complications related to type 2 diabetes and cardiovascular disease. As we seek to prevent or significantly delay the progression of chronic kidney disease, we add dialysis-free years for our patients. This has significant quality of life and cost of care implications.

Dr. Turck:
With that being said, Dr. Basina, what kinds of team structures and care coordination are needed in order to detect chronic kidney disease early on?

Dr. Basina:
It is always important to utilize and to be able to have a multidisciplinary team, to take care of those patients. Because it’s important to try to find patients, in order to utilize resources that we have appropriately. We need to be able to decide when the referral to nephrology is appropriate and needed, because as we know, wait time for new patients to be seen in nephrology clinic is fairly long, and we don’t want to wait for too long because of the implementation of the treatment that we currently have, to delay the progression, of the kidney disease. We also need to stratify the patients who may be able to be followed by primary care physicians. And again, for primary care physicians to be able to use the treatments appropriately and test at specific intervals. Multidisciplinary teams should include dietitians that are extremely important to discuss healthy and kidney-friendly diet with our patients. Patients who are still smoking need to be referred to smoking cessation. Weight management is very important, as well as the physical activity, and that could be to the patients would need to be referred to classes if available for weight management or group exercise programs.

Dr. Turck:
And before we close, Dr. Basina, do you have any final recommendations on how we can improve care coordination for these patients, going forward?

Dr. Basina:
I think the most important is to raise awareness that early detection of kidney disease, in order to prevent progression to end-stage renal disease Emphasizing to primary care physicians the importance of doing tests appropriately, at regular intervals, and when to refer to specialists. Regular assessment and risk stratification to be done at the regular intervals. That early initiation of the medications with known protective benefits for kidney disease – the medications that are shown to delay the progression of and worsening of kidney disease to start those medications early in the course of the treatment. Also, to overcome therapeutic inertia, even in terms of the diabetes control, from my standpoint as an endocrinologist not to wait for months and years to improve glycemic control but starting titrating the medications, and doing regular checkups with the patient, to be able to have more aggressive approach for glycemic control, blood pressure control and cholesterol management. And again, as we previously mentioned, utilizing multidisciplinary team for care of the patient, including several different specialists and our ancillary services would be extremely important in our practice.

Dr. Turck:
Well, those strategies to detect chronic kidney disease and coordinate patient’s care have been extremely helpful. And as that brings us to the end of today’s program, I want to thank Dr. Marina Basina and Dr. Eugene Wright, for sharing their insights. Dr. Basina, Dr. Wright, it was great speaking with you both today.

Dr. Basina:
Thank you very much for having us and for organizing this program.

Dr. Wright:
Thank you for having me, and very important topic to discuss.

Announcer:
This episode of Diabetes Discourse was sponsored by Renalytix. To access this episode and others from this series, visit ReachMD.com-slash-Diabetes-Discourse, where you can Be Part of the Knowledge. Thanks for listening!