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

Amy Mottl, MD

Data from the CURE-CKD Registry detailing the current rates of chronic kidney disease (CKD) have brought new attention to an ongoing problem that has been plaguing nephrologists for years.

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

Although rates of CKD in this population had deceased from 2015-2020, the treatment of CKD in people with diabetes has undergone a revolution with the revelations of the cardiorenal protective benefits associated with use of SGLT2 inhibitors and the development of the novel, selective, nonsteroidal MRA finerenone. With these new therapeutic options in hand, one might expect the community to look ahead to the future with optimism, but that is not always the case. Despite these advances, patient education and access, as well as a declining workforce, have left nephrologists with a sizable problem and no immediate answers.

While on-site at Physicians’ Education Resource’s6th Annual Cardo-Endo-Renal Collaborative, Endocrinology Network sat down with Amy Mottl, MD, associate professor of medicine at the University of North Carolina School of Medicine, for further perspective on the recent data and contemporary trends in CKD.

Endocrinology Network: What was your reaction to the recent CURE-CKD registry data and do you agree with the authors assessment of current rates being “troubling”?

Mottl: We are making some headway. If you're going to look at the most extreme case of end stage kidney disease, instead of seeing rates increasing, in terms of incidence, we're seeing it start to at least level off some. Prevalence, however, continues to increase because there are so many people with diabetes, hypertension, and obesity, which is an independent risk factor for kidney disease, as well.

So, it is hugely troubling. I think what is a little more troubling, just thinking about it from a sociopolitical platform, is why are we behind and really improving outcomes for this large population? That is partly due to lack of publicizing it, but also Black and Brown communities being socioeconomically marginalized. Those are huge risk factors for CKD and I can't help but think that that has also contributed to the lack of urgency for not only treating but just testing for this disease. Currently, the screening rates are terrible. Everyone gets a creatinine because it's on a basic metabolic panel, but nobody gets albumin-to-creatinine ratio and we really need to increase the uptake of that so we can actually treat people.

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

Mottl: I think we're really in a bit of a pickle right now because we don't have enough nephrologists to deal with the growing population of CKD. People just aren't going into nephrology as a specialty much as they used to. So, we're limited in who we can see and that, in and of itself, is problematic. I think there's also a lack of appreciation for what a nephrologist can do for a patient with CKD. A lot of times, primary care providers are so stuck, and they really are the front lines of our healthcare system, but their patients want to talk about all of the things that are making them feel physically poorly. So, primary care physicians have a hard time pulling in some of those other factors that play a huge role in that person's future and prognosis. It is concerning, but I understand it.

So, that's one issue: primary care providers are just over overworked and underpaid. However, there is also the fact that, up until recently, we did not really have a whole lot to offer. Now, that's completely changed. So, I'm hopeful that it will start to make a little bit of a turnaround as well. I think nephrology is just not very well understood by anybody else, that's not a nephrologist. Again, what we can do? One thing that kind of goes by the wayside, but that I feel strongly about, is educating patients. I think when patients come to a nephrologist and hear from an expert about their disease and the prognosis that it carries, it can really light a fire under people to make changes in their lifestyle and lifestyle changes are at the crux of treatment and delaying disease progression.

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

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