Chronic Kidney Disease

@ckd_ce on Twitter

1) Welcome to our new #tweetorial on optimizing #interprofessional & #multidisciplinary care & medical therapy for patients with #DKD. I am Sophia Ambruso DO, @sophia_kidney, from @CU_Kidney.

2) This #accredited #tweetorial series on #kidneydisease #DKD through the lens of #T2D is supported by an independent educational grant from the Boehringer Ingelheim/Lilly Alliance and is intended for healthcare providers. Faculty disclosures are at https://ckd-ce.com/disclosures/.

3) This activity is accredited for 0.75h credit for #physicians #physicianassociates #nurses #NPs #pharmacists. Past programs still eligible for credit can be found at http://www.ckd-ce.com. FOLLOW US for more programs by expert faculty!

4) We must view the optimal approach to #DKD in the context of #DM as a global health crisis, affecting
~27-31 million ppl (8.2% of US population)
~400 million ppl worldwide
๐Ÿ”“

https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

5) As of 2018, crude prevalence of #ESKD attributable to diabetes was 38.6%. Diabetes is the leading cause of #CKD worldwide, accounting for up to 50% of all patients with ESKD.

6) Based on a study in 2015, the world use of kidney replacement therapy #KRT is projected to double by 2030, highlighting the #CKD disease burden and global challenges ahead.

https://doi.org/10.1016/s0140-6736(14)61601-9

7) There were an estimated 219,451 deaths attributed to diabetic kidney disease #DKD, โžก๏ธapproximately 35% of ALL CKD deaths in 2017 worldwide.
See below: diabetic kidney disease mortality per 100,000 worldwide in 2017
๐Ÿ”“

https://link.springer.com/article/10.1007/s11892-019-1133-6

8) The combination #DM+#CKD โžก๏ธindependent & additive effect on #CV risk & mortality.
For every halving of #eGFR, CV incidence is 2x higher.
For every 10x โฌ†๏ธin baseline urine albumin, CV event incidence is 2.5x higher.
๐Ÿ”“https://pubmed.ncbi.nlm.nih.gov/22051245/
๐Ÿ”“

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3993088/

9) #CKD itself contributes to disease burden with dramatic impacts on quality of life in advanced #CKD and #dialysisdependent #ESKD made worse by #T2D
https://doi.org/10.2215/CJN.08730621

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3439392/

10) To get ahead of & reduce the impact #T2D & #DKD, coordinated efforts for early ID & intervention are necessary to slow disease progression. While the medical community has made strides, gaps & barriers at patient, physician, & system levels remain

https://doi.org/10.1053/j.ackd.2021.02.001

11) One in 7 of US adults have CKD, 90% of whom donโ€™t know it. Moreover, 40% with SEVERE CKD donโ€™t know they have CKD
๐Ÿ”“

https://www.cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fkidneydisease%2Fpublications-resources%2F2019-national-facts.html

12) An estimated 90% of patients with #DKD are undiagnosed & 40% with severe #DKD go undiagnosed

https://doi.org/10.1053/j.ackd.2021.02.001

13) With disease progression comes increased #CKD awareness, 40% with CKD IV and 60% with CKD V.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075598/

14) However, CKD awareness does not by itself lead to healthy, risk reduction behaviors ie. tobacco/NSAID avoidance, exercise, ACEi/ARB use; suggesting barriers at the patient & provider level
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075598/

https://www.karger.com/Article/FullText/346712

15) The recognition of #CKD by medical professionals has increased from 2006-2009 to 2014-2017, where coding for CKD increased from 3.2๏ƒ 52.3%. However, still almost half of patients with CKD go undiagnosed.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2757881

16) Physicians still underprescribe proven #renoprotective meds, and overprescribe potentially harmful drugs. Below is unadjusted prevalence of prescription drugs #SGLT2i, #ACEi, #ARB, #PPI, #NSAID in CKD 3a-5
๐Ÿ”“

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2757881

17) In short, barriers persist in #DKD awareness, detection and provision of evidence-based interventions at the patient, provider and systemic levels.

18) Fortunately, there are existing and emerging, evidence-based therapies that provide new hope in management of #T2D and #DKD and possibilities an improved #DKD global trajectory

Litecoin Ltc GIF

19) So, to kick off our discussion of treatment, tell me, the most familiar renoprotective agents in #DKD known to alter glomerular hemodynamics are which of these?

20) Mark your best answer and return tomorrow for a continuation of this programโ€”we will focus on TEAM management! @NWiegley @kkalra_22 @ghobby @priti899 @JohnRMontford @NamrataYParikh @CharlieTomson @DiMiRenalMD @KIDNEYcon @GlomCon @MedTweetorials #FOAMed @aakashshingada

21) Welcome back! We are focusing on optimizing #interprofessional & #multidisciplinary #TEAMWORK in the management of #diabetic #kidneydisease #DKD. I am @sophia_kidney and YOU are earning ๐Ÿ†“CE/#CME! ๐Ÿ‘to @divyaa24 @rheault_m @ChristosArgyrop @nephondemand @edgarvlermamd

22) The goal of #DKD treatment is three-fold:
I. reduce concurrent or continued injury by addressing modifiable risk factors
–Glycemic control (goal A1c <7)
–Weight loss
–Smoking cessation
–BP control (goal <130/80)
–Low salt diet
๐Ÿ”“

https://www.ajkd.org/article/S0272-6386(17)31102-2/fulltext

23) Goal of #DKD treatment is three-fold:
II. medicines that improve glomerular hemodynamics
III. medicines with anti-inflammatory/antifibrotic activity
๐Ÿ”“

https://www.ajkd.org/article/S0272-6386(21)00473-X/fulltext

24) The most familiar renoprotective agents in #DKD that alter glomerular hemodynamics are #RAASi agents (#ACEi & #ARBs) & #SGLT2i (& there's ur answer for theโ“ in tweet 19). See
https://www.nejm.org/doi/full/10.1056/NEJMcibr1608564 & for more CE/#CME on DKD tx, spend some time at https://ckd-ce.com/category/dkd/.

25) For years, RAASi through ACEi and ARB have solely been relied upon as the most reliable renoprotective therapies in #DKD.

26) The emergence of SGLT2i, GLP-1 agonists and steroidal MRAs have transformed the landscape of #DKD treatment, offering new therapy options and new hope.

27) Unfortunately, achieving widespread community healthcare provider understanding of drug mechanisms, cardiac and renoprotective roles, indications for use and comfort in prescribing remains challenging.

28) SGLT2i are perhaps the best understood with the most diverse indications for use with some of the strongest supporting clinical data.
https://doi.org/10.1053/j.ajkd.2020.08.003
๐Ÿ”“

http://www.nephjc.com/news/dapa-ckd

29) GLP-1 agonists are emerging as another promising #renoprotective agent with glomerular hemodynamic & anti-inflammatory/antifibrotic properties.
https://en.wikipedia.org/wiki/Incretin
๐Ÿ”“

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657126/

30) The GLP-1 agonist #CV outcome studies summarized below revealed mixed kidney outcome results but strongly trend towards renoprotective activity through reduction in albuminuria and/OR better secondary composite kidney outcomes

https://www.nature.com/articles/s41581-020-00367-2

31) AMPLITUDE-O results (2021): That secondary composite renal outcome (UACR >300, UACR โ‰ฅ30% increase from baseline, ESRD or death from any cause) favored efpeglenatide
๐Ÿ”“

https://www.nejm.org/doi/full/10.1056/NEJMoa2108269

32) Below are summaries of current and future clinical trials and evidence of albuminuria reduction vs GFR loss for #SGLT2i, #GLP-1 agonists (and #DPP4i).
See ๐Ÿ”“https://kdigo.org/guidelines/diabetes-ckd/
๐Ÿ”“

http://www.nephjc.com/news/dapa-ckd

33) Per @goKDIGO 2020 recommendations, the antihyperglycemic #T2D + #CKD algorithm (along with #RAASi, #bloodpressure mgmt & lifestyle modification) includes #metformin & #SGLT2i, and then a #GLP-1 agonist as the next preferred agent.
See ๐Ÿ”“

34) Letโ€™s turn our attention to the antihypertensive therapy of mineralocorticoid receptor antagonists #MRAs

35) Preclinical data reveal #MRAs:
–reduce oxidative stress, proinflammatory mediator activity and tubulointerstitial fibrosis
–contribute to glomerular (and cardiovascular) remodeling
–โฌ‡๏ธ albuminuria

https://www.nature.com/articles/s41581-021-00490-8

36) Preclinical models suggest more effective anti-inflammatory and antifibrotic activity w/nonsteroidal MRAs
&
The anti-androgenic & progestogenic adverse effects w/steroidal #MRAs, however less apparent with eplerenone, are suboptimal . . . and

https://pubmed.ncbi.nlm.nih.gov/30664703/

37) Clinical data w/nonsteroidal MRAs demonstrated various combinations of reduced albuminuria and/or reduction in primary composite outcome of kidney failure, sustained decrease in eGFR of 40% or more, or death of renal cause.

38) #FIDELIO-DKD, #RCT of finerenone vs placebo in CKD outcomes in #T2D vs placebo. Primary outcome: kidney failure, sustained eGFR decrease > 40% or death from any renal cause, N = 5674, favored finerenone, 17.8% event rate vs 21.1% w/placebo
๐Ÿ”“

https://www.nejm.org/doi/10.1056/NEJMoa2025845?url_ver=Z39.88-2003

39) The American Diabetes Association @AmDiabetesAssn recommends a combination #RAASi, #SGLT2i, #GLP-1 agonists and/or nonsteroidal #MRAs (#finerenone), as guided by #UACR, serum creatinine and comorbidities.
๐Ÿ”“

https://diabetesjournals.org/clinical/article/40/1/10/139035/Standards-of-Medical-Care-in-Diabetes-2022

40) How to reconcile gaps in #DKD care w/new promising renoprotective medications?
Through coordinated #multidisciplinary & #interprofessional approach for early diagnosis & tx. @KatherineTuttl8 @JoshuaNeumiller & Dr. Alicic have outlined strategies
๐Ÿ”“

https://doi.org/10.1053/j.ackd.2021.02.001

41) We'll talk about that TOMORROW as we wrap this up & give all #physicians #physicianassociates #nurses #nursepractitioners #pharmacists a CE/#CME credit grab! Join us, @GoggleDocs @Juajal @DrPSVali @bilalksheikh @drpriyajohn @Shaque89_ @DoctorGates @kidneydoc101 @SusanQuaggin

42) Welcome back! You're in the home stretch as we talk about TEAM-based management of #DKD. I am @sophia_kidney reminding you there is no "I" in TEAM but there is a "T": for education by TWEETORIAL! @ValleAlfonso @ArgaizR @DrRaymondHsu @GrahamAbra @Dilushiwijay @jaykoyner

43) As a recap, weโ€™re discussing how to reconcile gaps in #DKD care with the promising #renoprotective medications emergence

44) We can start by empowering providers to improve #CKD screening, recognition & management and provide resources like NKFโ€™s CKD Change Package that provides process improvements and educational resources
๐Ÿ”“

https://www.kidney.org/contents/chronic-kidney-disease-change-package

45) & provide multidisciplinary educational activities that introduce and discuss benefits and management tips of cardiac & renoprotective agents SGLT2i, GLP1 agonists and nonsteroidal MRAs.
๐Ÿ”“

https://www.ahajournals.org/doi/10.1161/CIR.0000000000000920

46) American Society of Nephrology @ASNKidney developed the Diabetic Kidney Disease Collaborative (DKD-C), a conference where nephrologists and primary care physicians collaborate to implement new #DKD therapies
๐Ÿ”“

https://www.asn-online.org/dkd-c/

47) #Multidisciplinary educational activities will empower providers in the community space to learn management strategies and share experiences on the diagnosis and management of #DKD.

48) With the significant overlap of care with #PCPs, #pharmacists, #cardiologists, #nephrologists & #endocrinologists, the stay-in-your-lane mentalities should be challenged.

Chan Clan Spiderman GIF

49) We must be able to rely upon the expertise of our providers that care for patients with diabetes and closely collaborate with them; nephrologists, PCP, cardiologists, dieticians, #socialworkers.

Working Marc Rodriguez GIF

50) As nephrologists, we often see patients more frequently than they see their PCPs. We should begin to feel comfortable adjusting or replacing diabetes medications.

We Trained For This When We Signed Up Were Prepared For This GIF

51) Leveraging #pharmacists can substantially reduce the care burden by performing med adjustments, med reconciliation (NSAIDs, PPIs), patient education and adherence to cardiorenally protective meds (ACEi/ARB)

52) In one meta-analysis, multidisciplinary models lowered all-cause mortality of patients with CKD, temporary catheterization rate, hospitalization rate and slowed eGFR decline See ๐Ÿ”“

https://link.springer.com/article/10.1007/s11255-017-1679-7

53) For this to be successful, clinical practice standards & guidelines must be congruent between organizations like @AmDiabetesAssn, @goKDIGO, @American_Heart and easy to understand. Here is the #ADAs practice guidelines for #PCPs
๐Ÿ”“

https://diabetesjournals.org/clinical/article/40/1/10/139035/Standards-of-Medical-Care-in-Diabetes-2022

54a) @goKDIGO compiled a โ€˜top 10 takeawaysโ€ for providers summarizing the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in #CKD
๐Ÿ”“

https://kdigo.org/wp-content/uploads/2018/03/Top-10-Takeaways-Clinicians_Updated.pdf

54b) So . . . did you pay attention? Per those @goKDIGO โ€œTop 10 Takeaways,โ€ what is the desired target A1C for glycemic control in DM+CKD?

55) Next, offering diabetes self-management programs #DSMP facilitated by health-care professionals tailored to patients with diabetes is needed

https://doi.org/10.1016/S2213-8587(17)30239-5

56) Below is a summary of studies focusing on benefit of #DSMP for #T21 & #T2D: Improvement in A1c, improvement in quality of life, reduced diabetes assoc hospitalizations & sustained improvement in physical activity

https://doi.org/10.1016/S2213-8587(17)30239-5

57) Diabetes self-management programs uptake: in the National diabetes audit 2013-2014 and 2014-2015, only 6.8% of privately health-insured people with #T2D attended #DSMP.
๐Ÿ”“

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6346a2.htm

58) Similar numbers were seen in the UK from 2014-2015
๐Ÿ”“

http://content.digital.nhs.uk/catalogue/PUB19900/nati-diab-rep1-audi-2013-15.pdf

59) Access to #DSMP varies globally and reasons individuals do not participate are complex.

https://doi.org/10.1111/dme.13120

60) #DSMP โ€“ how to improve uptake โ€“ the following must be improved;
-Patient awareness โ€“ benefits/harms of disease
-Affordability
-Accessibility
-Culturally appropriate
-Language

61) While barriers to #DKD management exist, they are not insurmountable. New therapies slowing progression of #DKD have given the healthcare community new hope.

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62) Through a coordinated, multidisciplinary and interprofessional approach, we can improve #DKD awareness, diagnosis & treatment while altering the trajectory of #DKD worldwide.

63) And that is IT! You made it! Go to https://ckd-ce.com/dkd8/ and claim your 0.75h ๐Ÿ†“CE/#CME credit! And FOLLOW US here on @ckd_ce (and don't miss @cardiomet_CE) for more education by tweetorial! I am @sophia_kidney
#nephtwitter #cardiotwitter @academiccme #FOAMed #endotwitter

Originally tweeted by @CKD_ce (@ckd_ce) on April 5, 2022.