HJNO Jul/Aug 2024

CHANGING THE CARE: CHRONIC KIDNEY DISEASE 32 JUL / AUG 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS   preferences; and helping patients manage exercise routines, all while constantly learning from their outcomes to drive loops of continu- ous improvement. Sadly, and unfortunately, tra- ditional health systems cling to a mindset that poor health outcomes are beyond their control and even resort to blaming the patients for their outcomes. But disruptive innovators like Strive already know that where there is a will, there is a way, and that improving outcomes and saving money is simply a function of a growth mindset that constantly learns from the mistakes of the past to create a better future. Difficult Choices Nobody ever wants to become afflicted by ESKD, but — at least for now — many people are faced with some difficult choices for ESKD each year. By choice, I’m referring to the mul- tiple choices that a patient with impending ESKD must confront: 1) hemodialysis (HD) in a dialysis center, 2) home hemodialysis, 3) perito- neal dialysis (PD), or 4) palliative care/hospice. Too few patients receive comprehensive, liter- acy-level-appropriate education about these various options. And hemodialysis in a dialysis center has traditionally been the most popular choice, but any person who fully comprehends a future of hemodialysis in a dialysis center could reasonably ask why. Although it has tradi- tionally been the most financially lucrative form of dialysis for providers and dialysis centers, it is arguably the most miserable for patients. It typ- ically requires a patient to visit a hemodialysis center three times per week for multiple hours each time. Those who undergo this form of di- alysis usually describe it as an exhausting ex- perience, often clinging to hope that a kidney will become available for transplant thereby re- storing at least some measure of quality of life. While peritoneal dialysis (PD) is not the right choice for everyone, it can generally be per- formed while they are sleeping in the comfort of their own home and without many of the complications fraught from HD. Granted, PD may not be the best option for persons with se- vere obesity and they need to reside in a place large enough to store the dialysis supplies re- quired for home dialysis. In a study published in Kidney International Reports in October 2023, the authors of this article attempted to understand why PD is not chosen more often. 1 “Peritoneal dialysis (PD) offers lifestyle advan- tages over in-center hemodialysis (HD) and is less costly. However, in the United States, less than 12% of end-stage kidney disease (ESKD) patients are maintained on this modality. In this brief review, we discuss some of the fac- tors underlying the low prevalence of PD. These include inadequate patient education, a shortage of sufficiently well-trained medical and nursing personnel, absence of infrastruc- ture to support urgent start PD, and lack of support for assisted PD, among other factors.” And despite healthcare’s traditional mind- set of focusing on extending life at all costs, there are clearly well-educated people of certain ages and co-morbidities who would reasonably choose palliative care and hos- pice over any dialysis option. Investing in resources to help educate patients com- pletely about all available dialysis options is essential to helping our patients choose the option that best meets their unique needs, values, goals, and preferences. But as reason- able as that may sound, it is still too much of a rarity in much of our current healthcare system. Not Having to Choose at All The best choice of all, of course, would be not having to make such a difficult choice at all. In part A of this article, we discussed how achieving 90+% rates of disease control across a population for hypertension and diabetes is already the standard of care for digital solu- tions in managing these conditions. Over time, that performance alone should help reduce the incidence and prevalence of advanced CKD and ESKD. But even without that level of per- formance, as of May 2024, we are already at a point in time where we can slow the progression of CKD down to only 2 to 3 mL/min per year for most patients, especially those with diabetes. To understand why, we need to go back in time before the development of successful interventions to slow the decline in estimated glomerular filtration rate (eGFR). In persons without diabetes or hypertension, the average rate of decline in eGFR averages about 1 mL/ min/year. As discussed in the last article, this decline usually does not impact us significantly during our normal lifespan. In other words, in those of us not afflicted by diabetes or hyper- tension, we typically succumb to a fate other than CKD. But in those with conditions that ac- celerate the progression of CKD, without thera- peutic intervention, this decline can be as much as 10 mL/min/year, meaning that by the time a person reaches CKD stage 3 (eGFR < 60 mL/ min), the progression to ESKD can occur in less than six years. By the early 1990s, the advent of a class of medications known as ACE inhibitors were shown to favorably reduce the amount of albumin lost in the urine (albuminuria), thus slowing decline in renal function down to around 6 mL/min/year. In the early 2000s, an- other new class of new medications known as the angiotensin receptor blockers brought that rate of decline in eGFR down to 5 mL/min/year, meaning that it could now take over 10 years to reach ESKD if these medications were prop- erly utilized. In the years leading up to 2020, the SGLT2 inhibitors demonstrated further improvements in this rate of decline down to as low as 3 mL/min/year. And within the past couple of years, yet another class of medica- tions known as the nonsteroidal mineralocor- ticoid antagonists (NS-MRA) have been shown to reduce this rate of decline even further. The first medication in this class is called finerenone and is already available, with evidence clearly demonstrating its significant renal benefits, especially in persons with diabetes. Using an ARB, SGLT2 inhibitor, and NS-MRA together in combination with one another can yield a rate of decline in eGFR of only 2 mL/min/year and represents a dramatic advance in the man- agement of CKD and will give many patients the option of not having to make a difficult choice regarding which option for ESKD at all. Furthermore, these medications all confer significant benefits regarding their impact on urine albumin-to-creatinine ratio (UACR). The recently published Kidney Disease Improving Global Outcomes (KDIGO) CKD guidelines il- lustrate the importance of UACR across multi- ple disease states. Monitoring and implement- ing therapeutic interventions that drive down UACR will become as important as managing high blood pressure and diabetes, favorably impacting not only the rate of decline in kid- ney function, but also the incidence and preva- lence of all forms of cardiovascular disease and overall mortality. Correspondingly, UACR will become one of the single most important metrics to routinely track and monitor across