Efforts to successfully target chronic kidney disease with a view to optimal management and achieve the goal of living well with chronic kidney disease will require a coordinated approach involving the private and public health care organizations, the government, all levels of healthcare providers, along with education of the population, to institute a national data base of chronic kidney disease, institute guidelines for management and specialists referral, according to nephrologist Dr. Adrian Sawyer.
He said all parties involved need to recognize that improved health outcomes require funding that everyone will have to contribute to, given the increasing expected prevalence of diabetes, obesity, hypertension and chronic kidney disease expected over the next decade.
“Non-dialysis-dependent chronic kidney disease has been estimated to affect approximately 19.2 million adults in the United States, according to the National Health and Nutrition Examination Survey (NHANES iii) 2003, reflecting a prevalence of 11.0 percent of the population,” said Sawyer. “This population has an increased risk of premature death of up to five times of that of their age-matched non-chronic kidney disease counterparts.”
According to Sawyer who currently serves as medical director at The Dialysis Centre Bahamas, the major cause of death risk is related to cardiovascular-related events such as myocardial infarction (occlusion of blood vessels of the heart, otherwise known as heart attack); congestive heart failure; strokes; and peripheral vascular disease (occlusive arterial disease of the lower limbs); and increased susceptibility to death from infections also contributes as the current pandemic evidences.
“The major drivers of the increased mortality are diabetes, hypertension, abnormal lipids [cholesterol blood levels], smoking, vascular disease [atherosclerotic] compromise of blood vessels, reducing blood supply, inflammation related to kidney disease [and] age increasing vintage [which] is associated with declines in kidney function.”
Sawyer said the majority of persons with chronic kidney disease will die from the above before kidney function is reduced to stage five requiring dialysis or transplantation. “Given that the non-medication-related cost of providing dialysis ranges from $80,000 to $95,000 per year per patient, the disproportionate burden of national health expenditure is evident,” he said. “Intensive medical management of patients with chronic kidney disease by nephrologists, cardiologists, endocrinologists and primary-care physicians can significantly slow the progression to end-stage kidney disease and reduce the cardiovascular complications, thereby improving quality of life for such affected individuals. Only by addressing these issues will the goal of living well with chronic kidney disease be achieved.”
Sawyer said establishing a national data base of the population with diabetes, hypertension and chronic kidney disease are among measures to achieve objectives in chronic kidney disease management.
“Since diabetes and hypertension together contribute to approximately 70 to 75 percent of the causes of CKD, identification of the at-risk population is imperative. This will require efforts at population and primary care physician education with a view to funding for the necessary blood and urine testing required for diagnosis and staging of CKD both in the public and private medical sectors.”
Sawyer said educating patients and physicians of the need for compliance with their prescribed treatments and appropriate clinical follow-up appointments and blood and urine testing is paramount.
“These should be done at least annually in persons at risk, and every four to six months in those with established chronic kidney disease, preferably having been referred to nephrology for specific kidney directed management. Studies have shown that late specialist referral is associated with worse clinical outcome.”
Education about adoption of healthy lifestyles including exercise, salt-restricted, low fat and carbohydrate diets with vegetables, such as the Mediterranean Diet he said is also important.
The monitoring of blood sugars at home with validated monitoring instruments to keep blood sugars as close to normal as possible, and the use of a validated home blood pressure monitor to record blood pressures at home for at least three days per week, with two recordings in the mornings and two recordings in the evenings, he said is also important.
“There is evidence to show that when done appropriately, these correlate well with continuous blood pressure monitoring devices that track blood pressure over 24 hours. The new definition of hypertension has been changed since 2017 to a lower threshold of greater that 130/ 80, and trial evidence that treating systolic pressures to a target of 120.0 is associated with less mortality and better outcomes, compared to treating to the previous target of 140/90. Institution of the above measures have been shown to slow the decline in filtration rate in those with CKD.”
Sawyer said nephrologists and cardiologists are the most appropriate specialists to manage hypertension, lipid (cholesterol) issues in CKD patients by utilizing a class of medications that affect specific hormone systems, that have been proven to slow the rate of kidney decline over the last 20 years.
“Timely appropriate nephrology [kidney specialist] referral for evaluation of additional kidney-specific risk factors and management will optimize care and delay the onset of dialysis-requirement treatments by months to years, thus improving quality of life.”
The doctor said over the last three years, newer agents for treating diabetes, by reducing the amount of glucose that the kidney reabsorbs, have been shown to improve blood sugar control, reduce cardiovascular outcomes, along with reducing heart failure and slowing the rate of decline in kidney function, have been introduced into clinical practice.
He said the use of drugs that lower blood cholesterol have also been shown to substantially reduce cardiovascular risk mortality in CKD patients and should be used aggressively. And that patients with diabetes, will benefit from daily aspirin to reduce their stroke and heart attack risks.
“Unfortunately, all of the above measures result in increased costs of care, and it is not unusual for the CKD patient to actively be on six separate medications to optimize cardiovascular risk. Regular blood, urine and cardiology imaging tests add to costs of management and are disincentives to patient compliance, unless there is third-party [insurance] coverage. Once patients progress to dialysis treatments, their insurance coverage limits are reached within one to two years and with job loss, the associated income loss impedes quality of life, leading to dependency and loss of autonomy.”