Monitoring and Following Patients With Chronic Kidney Disease
In this podcast, Kim Zuber, PA-C, explains the current gold standard for monitoring and following patients with chronic kidney disease (CKD) and what has been done to ensure standardized laboratory monitoring for early CKD. She also presented on this topic at the annual AAPA 2021 meeting.
- Chronic Kidney Disease in the United States, 2021. Centers for Disease Control and Prevention. Updated March 4, 2021. Accessed May 24, 2021. https://www.cdc.gov/kidneydisease/publications-resources/CKD-national-facts.html
- KDIGO 2021 clinical practice guideline for the management of blood pressure on chronic kidney disease. Kidney Int. 2021;99(suppl 3). https://doi.org/10.1016/j.kint.2020.11.003
- KDIGO 2020 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2020;98(suppl 4). https://doi.org/10.1016/j.kint.2020.06.019
- Zuber K. The ABCs of chronic kidney disease. Presented at: American Academy of Physician Assistants 2021 virtual; May 23-26, 2021. https://ww3.aievolution.com/aap2101/index.cfm?do=ev.viewEV&ev=1030
Kim Zuber, PA-C, is a physician assistant and the executive director of the American Academy of Nephrology Physician Assistants in St. Petersburg, Florida.
Jessica Bard: Hello everyone, and welcome to another installment of "Podcast360." Your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.
According to the CDC, about 37 million US adults are estimated to have chronic kidney disease and most are undiagnosed. Every 24 hours, 350 people begin dialysis treatment for kidney failure. Kim Zuber is here to speak with us about that today.
Kim is a physician assistant and the executive director of the American Academy of Nephrology PAs in St. Petersburg, Florida. Thank you for joining us today, Kim. You're presenting your session, "ABCs of Chronic Kidney Disease," at the annual AAPA 2021 Conference. Can you please give us an overview of your session, and why is this so important?
Kim Zuber: Chronic kidney disease is the most common chronic disease of any type in the United States, and it's one of the most under‑diagnosed. There's many as 9 in 10 adults who have CKD have no idea that they have kidney disease. One in three Americans are at risk, and more than one in seven actually has CKD.
The cost of CKD is 98 billion dollars, or 20 percent of the entire Medicare budget, just to pay for my patients. CKD is a very aggressive disease, and it can be slowed and stopped, but it needs everyone to work together and to catch it early.
Jessica: What is the current gold standard for monitoring and following patients with CKD? What has been done to ensure standardized laboratory monitoring for early CKD?
Kim: At the turn of the century, we introduced a staging system for kidney disease that includes both albumin and a GFR. The problem is, everybody does the GFR. Everybody checks the serum creatinine, but very few people actually check the urine. Less than five percent of patients with hypertension, which is the number two cause of kidney disease, ever have a UACR.
When I'm out speaking to other clinicians, I find that they don't realize how important that your albumin is. Albumin is pathognomonic for CKD, and it will go up prior to the drop in GFR. We need to get more and more clinicians to check the albumin. The National Kidney Foundation tried a different way.
They cheated and took an idea from the endocrine people. Endocrine has what are called fibroid function test, which is one check‑off box, and you don't have to remember what exactly to order. We have a kidney profile on all the big labs, the Quest, the Labcorp, the hospital labs that says "Kidney profile," and you don't have to remember to order both a urine and a serum creatinine.
Jessica: What is the goal blood pressure for patients with CKD? Why can these guidelines be confusing to many clinicians?
Kim: We just changed the guidelines. In February of 2021 we lowered the guidelines, and we don't know what the diastolic guidelines are, but for systolic, we want you in the 120s. We are now more aggressive than the cardiac people. Although, the cardiac people love our guidelines and are all in on them.
What we know is that for many years, we told people to be careful. Don't go too low, you may hurt the kidneys. What we have found is those patients, even if they do have an acute kidney injury that's transient, these people will do better in the long run.
Keeping people's blood pressure in the 120s is the magic point and, right now, our biggest problem is getting that information out because it was just published.
Jessica: The combination of CKD and diabetes significantly raises the risk of cardiovascular disease and death. Now, you just touched on this a little bit, but how has the management of CKD evolved over the last decade and, more specifically, treating patients with CKD and diabetes?
Kim: For the longest time, all we had were ACE and ARBs, all we had was some type of RAS treatment. With the SGLT‑2 inhibitors, which were introduced to help manage diabetes, when they went to look at how they did out in the general public, did they increase cardiovascular disease? Did they cause any problems with hearts? Were they cardioprotective?
What they did when they ran those studies is, they also figured, "You know, they work at the level of the kidney. We should probably keep an eye on the serum creatinine." We were an afterthought. We were just like, "Oh well, let's keep an eye on the kidney."
What happened was, it turned out that we were the best part of an SGLT‑2 and the kidney protection of these medications is phenomenal, a 39 to 41 percent drop in progression of kidney disease. What was an incidental finding when the companies looked for the cardiovascular disease, became the focus.
Then, we had CREDENCE, which was patients who had kidney disease who were given SGLT‑2s. Again, huge decrease in incidents and progression of kidney disease. Then, we had to question, "Well, if it works for the cardiac patient who has kidney disease, and if it works for the diabetic patient who has kidney disease, does it work for just the kidney disease population?"
Then, the last study was DAPA‑CKD which showed that not only did it work in our patient population, but as of two weeks ago there is an indication to give SGLT‑2s to patients with kidney disease, unrelated completely to diabetic.
What we now have is treatments for our patients, which for years, all we had was really a little blood pressure pill. Now, we've got significant treatments that we know can slow the progression and keep people off dialysis, which is our goal in the long run.
Jessica: What factors can be used to predict which patients with CKD will be more likely to progress to ESRD?
Kim: Males. Males are more likely, [laughs] which is OK with me.
Kim: Females are more likely to have CKD. Males are more likely to progress to kidney failure.
Jessica: That was easy.
Kim: It's also not curative. You can't really change those facts.
Jessica: What are the overall take‑home messages for our audience from your session today?
Kim: Right now, we are at the beginning of being able to change the outcomes, and it needs to be done earlier. By the time the patient gets to me in nephrology, they are at stage four, five, and I can't do much at that point. We need to get that information out to the primary care, to the cardiology, to the OB‑GYN, to the orthopedic.
Everybody needs to know that we can change outcomes. We have to identify the patient. We need to have a kidney profile or if you want to remember the word UACR, that's fine. We need to identify those patients, and then we need to jump on it. We need to jump on them early, treat them and that will slow the progression, and those patients won't end up on dialysis or even worse, in the ICU or in the cardiac cath lab.
Jessica: There is so much ground to cover here, but for today, is there anything else that you'd like to add at all?
Kim: We love to talk about kidney disease, and we are always happy to answer questions. There are not enough of us. There are 7,000 nephrologists in the United States. That's the same number of plastic surgeons in LA.
We are overwhelmed with patients, but we'd love to talk about kidney disease. Please ask us, and we know how to slow it down, but we need help because by the time they meet us, the die is cast. It's too late. Please ask us. We know the answers.
Jessica: Kim, thank you so much for your time today. We really appreciate you being with us.
Kim: Thank you for letting me talk kidneys.