Dr. Alicic
Hello and welcome. This is Dr. Radica Alicic, and today I will be hosting “Diabetes and Kidneys: Unraveling T2D’s Silent Threat.” In today's episode, we'll be discussing the management of chronic kidney disease associated with type 2 diabetes.  

We are all aware that patients with chronic kidney disease associated with type 2 diabetes often experience multiple long-term conditions.^1,2 They are at high risk of progression of kidney disease and cardiovascular events.¹ So, early identification and treatment of chronic kidney disease can slow its progression and reduce the risk of complications.3 And accurate diagnosis and staging add a critical aspect of managing these conditions effectively.^1,3  

The American Diabetes Association, ADA, and the Kidney Disease Improving Global Outcomes, KDIGO, consensus report stresses the importance of comprehensive, holistic, patient centered medical care for improved overall outcomes in these complex patients.¹  

So, in today's episode, we'll explore nonpharmaceutical strategies, including lifestyle modifications, and discuss the critical role of primary care clinicians in early identification and management of chronic kidney disease. Please note this discussion will not focus on specific pharmaceutical interventions. I'm so pleased to have with me on today's podcast, Dr. Jennifer Green. Could you please start by introducing yourself, Dr. Green? 

Dr. Green
Thank you very much, Radica. It's a real pleasure to be here today with you. And greetings from North Carolina. I'm an endocrinologist and diabetes and metabolism specialist at Duke University. 

Dr. Alicic
So, let's kick things off by addressing the guidelines used in managing chronic kidney disease associated with type 2 diabetes. Dr. Green, do you have specific guidelines that you find particularly useful, and what do you think are some important aspects of these guidelines?

Dr. Green
Oh, absolutely. So the guidelines from the ADA, that is, the American Diabetes Association and the International KDIGO Organization, are what I consider to be essential references in managing chronic kidney disease associated with type 2 diabetes.^2,4 And the synergy in these guidelines, following the recent updates and publication of a consensus report, I find very helpful.¹ And both organizations do now emphasize the need for a very comprehensive approach to the care of such patients.¹

Dr. Alicic
Indeed. Both the ADA and KDIGO stresses the importance of patients taking an active role in managing their condition.¹ The KDIGO guidelines even recommend a structured self-management education program for those with diabetes and CKD.² Is that correct?

Dr. Green
That's correct.² The ADA guidelines align with this, emphasizing the importance of diabetes self-management education and support, sometimes abbreviated DSMES, for all individuals with diabetes.⁵ And we know that DSMES is associated with numerous benefits, including a lower hemoglobin A1c, improved quality of life, and reduced health care costs.⁵

Dr. Alicic
Thank you. So, in your experience, what is a good time to introduce DSMES?

Dr. Green
Well, that's a great question, and I do think that we underutilize DSMES.⁵ It's really ideal to introduce it at critical times, of course, when a person is diagnosed with diabetes, but they often need a reassessment and refresher annually.⁵ And we should also consider this when treatment targets aren't met.⁵ So, for example, if blood glucose or weight or blood pressure, are not improving or at therapeutic goals.⁵ It's also important to consider redelivery of DSMES when there are complicating factors present and during major life transitions for individuals with diabetes and chronic kidney disease.^2,5

And even though DSMES is diabetes specific, it's also important for kidney health as there's quite a lot of overlap between diabetes and CKD and what we recommend to individuals with both of those conditions.^1,2,5 Further, it's important to remember that Medicare does reimburse DSMES when the services that are delivered meet national standards and are recognized by the ADA.⁵ It's also covered by most health insurance plans, fortunately.⁵ 

Dr. Alicic
Excellent points. Thank you so much. How important is patient engagement in their care?

Dr. Green
So, patient involvement in their care is, in my opinion, paramount.¹ Individuals with these conditions should be educated about the various aspects of their conditions.¹ They need to know about and engage in appropriate lifestyle modifications.¹ And of course, they need to actively participate in decision making about their care.¹ Being part of support groups, using available technologies and understanding test results are really also key components to the individual understanding and participating in their personal care.¹

Dr. Alicic
I completely agree with you. Thank you for pointing out importance of patient engagement.  
So, when patient with chronic kidney disease associated with type 2 diabetes comes into your office, what are your initial thoughts regarding next steps to slow the progression of kidney disease?

Dr. Green
Well, a holistic approach, or sometimes I call it a whole person approach, is really vital, and it must incorporate both lifestyle modifications and pharmaceutical interventions.¹ Both the ADA and KDIGO recommend that we establish a foundation of appropriate lifestyle changes before layering on or adding pharmaceutical interventions for blood pressure, glucose control, lipid management, and heart and kidney protection.¹ However, I will say that in many circumstances, we are delivering all of these aspects of care at the same time.² 

Dr. Alicic
Thank you, Dr. Green. And specifically, for healthcare providers in the primary care setting, what can they do to help slow chronic kidney disease progression?

Dr. Green
Well, the primary care clinicians have a critical role in this process, and it's important to remember that, for example, the Centers for Medicare and Medicaid Services consider many interventions in the primary care setting to be important for both the diagnosis and mitigation of risk of CKD progression in that setting, and these very appropriate activities would include the early identification of chronic kidney disease through regular screening, blood pressure and glucose management, interventions to reduce albuminuria in people with chronic kidney disease.⁶ And, of course, as I've mentioned previously, promoting a healthy diet and otherwise maintaining a healthy lifestyle.^1,6 And all of these interventions can fit very nicely within a primary care practice or setting.⁶ They're not isolated actions, but instead they're really integrated steps that coexist with the management of the many other chronic conditions that are managed by a primary care provider.⁶ And here's a noteworthy point from the ADA guidelines for individuals with known chronic kidney disease and urinary albumin levels of 300 milligrams per gram or higher, that is, a UACR that is severely elevated, a goal of reducing the urinary albumin by 30% or more is recommended to slow down the progression of chronic kidney disease.⁴

Dr. Green
And this is a targeted approach that aligns with the overarching goal of preserving kidney function.⁴ Remember that many of these interventions, so, for example, screening and identification of chronic kidney disease, are reimbursable activities.^7.8

Dr. Alicic
Excellent. Thank you. So, would you say these guideline recommendations will be easy to follow for our patients? And is there anything you would change about the latest guidelines for care of these patients?

Dr. Green
Well, to be honest, in my opinion, most chronic diseases are not terribly easy to manage.⁹ Lifestyle modification itself can be both difficult to implement and to sustain over time.^10,11 I think that's the reason why we really must reassess how our patients are doing in that respect, and to periodically reinforce any education or provide any additional support that they may need.¹⁰

Another really important aspect, I think, of the care that we deliver to our patients is making sure that they understand the rationale for why they should be making these lifestyle changes and what potential benefits they could be receiving from some of the medications that we prescribe.^1,12 I would note that KDIGO does provide some very patient friendly educational tools that I think can be very helpful in helping patients to understand why their CKD associated with type 2 diabetes is being managed in the way that we recommend.^13,14

Dr. Alicic
Thank you. I really appreciate that both KDIGO and ADA are putting now patients in a center of care and stress importance of their engagement.¹ As you pointed out, it is not easy to live with a chronic disease, especially for patients like these who do have multiple chronic medical conditions.^1,9 Lastly, let's discuss the role of primary care clinicians in early identification and management of chronic kidney disease. Maybe you could share your insights on the collaborative effort needed for successful patient outcomes?
 

Dr. Green
Well, absolutely. We know that there's a shortage of nephrology care providers,¹⁵ and at least in my area, the nephrologists are so busy that they're really focusing on patients who have end stage or very unusual causes of chronic kidney disease.^6,16,17 So primary care clinicians are at the forefront of early diagnosis and management efforts.¹⁷ And these routine visits at which these patients are seen really provide great opportunities for identifying risks for addressing the many potential barriers to self-management that we must consider when caring for patients.¹⁸ These, of course, can include access to medical care, healthy food, safe environments for physical activity.^6,18-20 These routine visits also can serve as the gateway to timely referrals to subspecialty care when needed.¹⁸ And I would point out that the KDIGO guidelines are very helpful in our understanding of when patients should be referred for nephrology subspecialty care.^1,21 Remember, though, that the success of any CKD screening program really relies very heavily on primary care clinicians and allied health professionals.³ And it is a shared responsibility for all of us to take steps to reduce risks and overcome barriers to high quality CKD care.^2,3

Dr. Alicic
Thank you, Dr. Green, for joining us today and providing your valuable insights. And to our listeners, we hope this episode had been informative. Remember, early identification intervention can make a difference in the lives of our patients dealing with chronic kidney disease and type 2 diabetes.³ Stay tuned for more in our “Diabetes and Kidneys: Unraveling T2D’s Silent Threat” series. Until next time, take care and stay well.