Managing CKD in the Face of a Growing Diabetes Epidemic, with Amy Mottl, MD

New data from the CURE-CKD registry detailing current rates of chronic kidney disease (CKD) has drawn attention to an ongoing problem that has plagued nephrologists for years.

Posted in the New England Journal of MedicineThe study results detail a slight decrease in CKD rates in people with diabetes, but the authors called the results “troubling” given the increasing prevalence of diabetes in the US population.

Although CKD rates in this population have died down between 2015 and 2020, the treatment of CKD in people with diabetes has undergone a revolution with revelations of cardiorenal protective benefits associated with the use of SGLT2 inhibitors and the development of the new selective non-steroidal ARM drug finerenone. With these new therapeutic options in hand, one would expect the community to look to the future with optimism, but that is not always the case. Despite these advances, patient education and access, along with a declining workforce, have left nephrologists with a daunting problem with no immediate answer.

At Physicians’ Education Resource’s 6th Annual Cardo-Endo-Renal Collaboration, Endocrinology Network spoke with Amy Mottl, MD, associate professor of medicine at the University of North Carolina School of Medicine, for a deeper perspective on recent data and contemporary trends in IRC.

Endocrinology Network: What has been your reaction to the recent data from the CURE-CKD registry and do you agree with the authors’ assessment that the current rates are “troubling”?

Password : We are progressing. If you look at the most extreme case of end-stage kidney disease, instead of seeing the rates go up, in terms of incidence, we see that they’re starting to at least level off. The prevalence, however, continues to rise because so many people have diabetes, hypertension, and obesity, which is also an independent risk factor for kidney disease.

So it’s extremely disturbing. I think what’s a bit more troubling, just thinking about it from a sociopolitical perspective, is why are we falling behind and really improving outcomes for this large population? This is partly due to the lack of publicity, but also to socio-economically marginalized black and brown communities. These are huge risk factors for CKD and I can’t help but think this has also contributed to the lack of urgency not only to treat but also to test for this disease. Currently, testing rates are terrible. Everybody gets a creatinine because it’s part of a basic metabolic panel, but nobody gets the albumin to creatinine ratio and we really need to increase the uptake of it so we can actually treat people.

Endocrinology Network: What can be done to improve the outlook for CKD in people with diabetes?

Password : I think we’re in real trouble right now because we don’t have enough nephrologists to keep up with the growing CKD population. People no longer turn to nephrology as a specialty like they used to. So we are limited in what we can see and that in itself is problematic. I think there is also a lack of appreciation of what a nephrologist can do for a patient with CKD. Often primary care providers are so stuck up, and they’re really the front lines of our healthcare system, but their patients want to talk about all the things that make them feel physically unwell. So primary care physicians struggle to integrate some of these other factors that play a huge role in that person’s future and prognosis. It’s worrying, but I understand it.

So that’s a problem: primary care providers are just overworked and underpaid. However, there’s also the fact that until recently we didn’t really have much to offer. Now it is completely changed. So hopefully that will start to do a bit of a turnaround as well. I think nephrology is just not very well understood by anyone who is not a nephrologist. Again, what can we do? One thing that gets a bit by the wayside, but is close to my heart, is patient education. I think when patients see a nephrologist and hear an expert talk about their disease and the prognosis it carries, it can really light a fire under people to make lifestyle changes and lifestyle changes are at the heart of the treatment and delay the progression of the disease. .

Editor’s Note: This transcript has been edited for length and clarity.

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