Overview of Diabetes and Renal Impairment

Dhiren Patel, PharmD, CECES, BC-ADM: Welcome to this Medical Economics® Around the Practice program titled “Management of Diabetes and Renal Impairment.” I’m Dhiren Patel, an adjunct associate professor of pharmacy practice at the Massachusetts College of Pharmacy [and Health Sciences] in Boston, and an endocrine clinical pharmacy specialist. Joining me in this discussion are Dr Robert Busch, the director of clinical research and a practicing endocrinologist at the Albany Medical College Faculty Practice in Albany, New York; and Dr Muthiah Vaduganathan, a cardiologist at Brigham and Women’s Hospital and faculty at Harvard Medical School in Boston, Massachusetts. Thank you both for taking the time to be here today.

Robert Busch, MD: Glad to be here.

Dhiren Patel, PharmD, CECES, BC-ADM: One thing we’re increasingly finding out in patients with diabetes is that it’s no longer just about diabetes. There’s a long list of comorbidities we need to take into consideration. I always say that I don’t know the last time I saw a patient who had only diabetes and I didn’t have to go through their past medical history and factor in 3 or 4 different things as I decide how to counsel that patient and what pharmacotherapy to consider. Dr Busch, can you talk a little about the prevalence of renal impairment? This is something we’ve always talked about from the beginning days where we’ve had to keep an eye on the patient’s eGFR [estimated glomerular filtration rate] as we think about drug therapy. What are you seeing in terms of the prevalence of CKD [chronic kidney disease] and diabetes?

Robert Busch, MD: It’s extremely common, but patients don’t know they have it. If the caregiver doesn’t inform the patient, the patient feels fine even though they could have stage IIIB chronic kidney disease with a GFR [glomerular filtration rate] of 35 mL/min and urine microalbumin that’s high, and they have no idea that they have kidney disease. When patients need a statin, they may choose not to take it, but they know they have a lipid problem. If someone has diabetes, they may choose not to treat it, but they know they have diabetes. But in terms of chronic kidney disease, they don’t know it unless they have a nephrologist or are heading toward dialysis. That’s pretty sad, because we have terrific drugs that could help, besides lifestyle, not taking an NSAID [nonsteroidal anti-inflammatory drug], keeping good blood pressure management, and giving the RAS blocker. We have a lot of drugs beyond RAS blocker that may benefit their kidneys, and unfortunately the patients don’t know it. It’s up to the caregiver to inform them about it. It’s very common.

Dhiren Patel, PharmD, CECES, BC-ADM: Dr Vaduganathan, when you talk about this and what you see, I would love to get the cardio-renal. There’s a huge implication in access. How should we be looking at this, and what’s the interplay as we talk about CKD, CV [cardiovascular] disease, and diabetes?

Muthiah Vaduganathan, MD, MPH: It’s a similar intersection that’s large and under-recognized. If routinely screened with not just eGFR but also UACR [urine albumin-to-creatinine ratio] measurements, urine albumin and creatinine measurements, the overlap is likely to be even more substantial between heart failure, chronic kidney disease, and diabetes. In fact, recent series of hospitalized patients with heart failure suggest that over 60% have some degree of chronic kidney disease. Unfortunately, the heart and kidney have been considered enemies for a long time in terms of therapeutics. In many cases, patients who are at that intersection face the highest risks for near-term mortality and clinical events, yet are treated with the least amount of medical therapy. There’s this unfortunate risk-treatment paradox where high-risk patients are undertreated. That needs to be corrected. It’s fortunate that we now have therapies that target the intersection that may simultaneously benefit the heart and kidneys and don’t necessarily work against one another.

Dhiren Patel, PharmD, CECES, BC-ADM: Absolutely. This is another space in which we haven’t had innovation in a really long time.

Transcript edited for clarity.