2) Christos Argyropoulos MD, PhD @ChristosArgyrop is Division Chief, Nephrology @UNMHSC. #CKD is chronic #kidneydisease, #ESKD is end-stage kidney disease.#FOAMed #nephtwitter #cardiotwitter @MedTweetorials @NephUCommunity @ISNkidneycare @KidneyDiseaseFm pic.twitter.com/NzvCEBGckA
— @CKD_ce (@ckd_ce) May 18, 2023
4) Let’s kick off this program with a case to orient us to the clinical problems. Your next pt in clinic is 60 ♀️ with 10y history of #T2D. She had had “pre-diabetes” for another 10 years prior to that, & her #A1c for the last year had been <7.0%.
— @CKD_ce (@ckd_ce) May 18, 2023
6) Before exploring the answer, let’s consider the problem(s) we are trying to solve in patients with #T2D. These problems burden individuals, public health and the financial health of healthcare systems & are shown in the infographic ⤵️https://t.co/YPVmXEEGOP pic.twitter.com/VsvW32NYfM
— @CKD_ce (@ckd_ce) May 18, 2023
8) Returning to the vignette, the patient has excellent glycemic control for the current guidelines (https://t.co/1cvvGEV1PN), so the focus should be on reducing the impact of #T2D on the #cardiovascular system and the kidney. pic.twitter.com/y79XAa88Q6
— @CKD_ce (@ckd_ce) May 18, 2023
10) Returning to the vignette, pt would benefit from quantifying her #cardiovascular & #kidney disease risk by ✔️:
— @CKD_ce (@ckd_ce) May 18, 2023
→cholesterol
→ kidney function (eGFR)
→ kidney damage (proteinuria) labs. The latter 2 are NOT part of the ACC/AHA risk calculatorhttps://t.co/jPIUrqRxag
12) Current guidelines say that a measurement of both kidney function (#eGFR) and damage (#proteinuria) must be obtained in clinical practice. For the latter we prefer the measurement of #albuminuria (as the ratio of urinary albumin to creatinine ratio #UACR in a morning) sample.
— @CKD_ce (@ckd_ce) May 18, 2023
14) Per the @AmDiabetesAssn standards of care the frequency of testing & clinical visits (see chart ↓) may be higher in patients with #T2D & #CKD, and the outcome of testing may be used to determine consultations and referrals within the healthcare system. pic.twitter.com/QluQPFDFn8
— @CKD_ce (@ckd_ce) May 18, 2023
16) The #RENAAL study examined various ways to measure kidney damage through:
— @CKD_ce (@ckd_ce) May 18, 2023
➡️ 24hr Protein (UPE)
➡️ 24hr Albumin (UAE)
➡️ First Morning Voided (FMV) Albumin/Creatinine
➡️ FMV Protein/Creatininehttps://t.co/eFZc5fAZzQ
While they all predicted #ESKD, #UACR was the best! pic.twitter.com/kjtWSBXovr
18) Given such data one could use two metaphors inspired by cardiovascular medicine:
— @CKD_ce (@ckd_ce) May 18, 2023
Kidney Function ↔️ eGFR ↔️ “Ejection Fraction” of the Kidney
Kidney Damage ↔️ UACR ↔️ Kidney’s “Cholesterol”
Both tests predict cardiovascular & kidney outcomes in #CKD & #T2D pic.twitter.com/V7jWpFVtKa
20) #UACR & #eGFR are also included in The Kidney Risk Failure Equation (#KRFE) first developed in in Canada by @NavTangri & subsequently validated in more than 700k patients from 30+ countries.
— @CKD_ce (@ckd_ce) May 18, 2023
Available in smartphone apps (e.g. @QxMD) and the web https://t.co/fHVGpqi5ub
22) The patient in our vignette had both these tests performed. Her #eGFR was 45 ml/min/1.73m2 and her #UACR was 500mg/gm creatinine. How does knowing the numbers help manage her risk at this point? Let’s put her on the #KDIGO heat map & the #KRFE and help her & us find out! pic.twitter.com/TJDvtxtbUl
— @CKD_ce (@ckd_ce) May 18, 2023
24) In having conversations about the next steps, one can use the #KFREcalculators.
— @CKD_ce (@ckd_ce) May 18, 2023
➡️4 Variable: Age, Sex, eGFR, UACR
➡️8 Variable includes the 4 Variable + Calcium, Phosphorus, Bicarbonate, & *Serum* Albumin. This version may discriminate better.
🔓https://t.co/Wdwfe8H9dX
26) According to the heatmap and #KFRE the patient has moderate #CKD but she is at high risk for #cardiovascular and #kidneycomplications. How does one reduce the risk of these complications from #T2D & #CKD ? Enter @AmDiabetesAssn's 4⃣-pillar model:https://t.co/lbvow6xusT pic.twitter.com/cjwPFpzhw8
— @CKD_ce (@ckd_ce) May 18, 2023
28) We need to do more to help our pts know their numbers.
— @CKD_ce (@ckd_ce) May 18, 2023
➡️In many areas in the 🇺🇸, measurement of #UACR lags behind measurement of the #eGFR https://t.co/TKIZTC22Hb
➡️There is large variation in obtaining #UACR even inside the same health care system!https://t.co/12ooufVimg pic.twitter.com/JX35UAFOvi
30) The evidence- & guideline-based answer to the previous poll is an unequivocal “All of the above”.
— @CKD_ce (@ckd_ce) May 18, 2023
➡️#UACR is an important diagnostic criterion for the presence of #CKD & the latter weighs heavily in selecting hypoglycemic agents for pts w/#T2Dhttps://t.co/pDe0X1xExl pic.twitter.com/taZmjtdJ3T
32) The use of #UACR to guide selection of further therapies in patients with #T2D & #CKD is firmly rooted in the concept of “residual risk”, i.e. the risk for the development of worsening kidney function and #cardiovascular risk among patients treated with #ACEi or #ARB.
— @CKD_ce (@ckd_ce) May 18, 2023
34) Residual #UACR has been a major criterion for inclusion in both the #SGLT2i
— @CKD_ce (@ckd_ce) May 18, 2023
🔓 https://t.co/SHvLIWWV3l
🔓 https://t.co/QItZmus6m5 (@priti899) &
and the non-steroidal #MRA #finerenone randomized controlled clinical trials #RCTs.
🔓 https://t.co/B8J9hRsFfL pic.twitter.com/TyBXbqHK3N
36) #UACR will continue to play a role for the development of future novel therapies in #CKD and #T2D as it fulfills the criteria for surrogate end point in clinical trials in early kidney disease.https://t.co/NzJ2L0Q2KF
— @CKD_ce (@ckd_ce) May 18, 2023
38) The analyses of #UACR as a surrogate marker included 28 cohorts with nearly 700k participants & 41 #RCTs.
— @CKD_ce (@ckd_ce) May 18, 2023
⬇️UACR reduction of 30% or eGFR slope ⬇️by 0.5 to 1.0mL/min/1.73m2 per year were associated with an HR of ∼0.7 for the clinical outcome of #ESKD in cohorts and trials pic.twitter.com/HnvsQz7ZIY
40) Furthermore, it
— @CKD_ce (@ckd_ce) May 18, 2023
👉 Can be used to select patients with #residual #UACRelevations for guideline guided medical therapies (#SGLT2i & #MRAs) in the present
👉 Will continue to be used to enroll patients in #RCTs of investigational drugs in the future.
Measure it! pic.twitter.com/eq6QobGT8x
42) The correct answer is UACR! The patient has had a good response to a maximal dose of an ARB by experiencing a drop in her #UACR by 40%, but she still has considerable albuminuria putting her at risk for cardiovascular & kidney complications, i.e. a #SGLT2i, #MRA or both.
— @CKD_ce (@ckd_ce) May 18, 2023
43) And you just earned 0.5hr 🆓CE/CME! Congratulations! Claim your certificate right now at https://t.co/x1nKRaEOfn & FOLLOW US while we are top of kidney . . . er, mind! @ChristosArgyropthanks you for tuning in!#FOAMed #nephtwitter #CardioTwitter #MedEd
— @CKD_ce (@ckd_ce) May 18, 2023