HJNO May/Jun 2024

HEALTHCARE JOURNAL OF NEW ORLEANS I  MAY / JUN 2024 27 kidney failure. CKD itself is an independently associated risk enhancer for the development of CVD, meaning that persons afflicted by CKD are at greater risk of developing and subse- quently dying from CVD or its complications. And these conditions are mutually interdepen- dent, because just as CKD is a risk enhancer for CVD, inadequately managed conditions that are most strongly associated with developing CVD — like poorly controlled hypertension and diabetes mellitus — can hasten the progression of CKD, accelerating kidney failure by decades. A little over a decade ago, the American Medical Group Association (AMGA) put forth an initiative called “Measure Up/Pressure Down,” a campaign intended to raise the av- erage rate of hypertension control across its members’ patients to > 80% rate of control (meaning 80% of their patients have a BP < 140/90). At the time, in the community where I was practicing, two of the largest primary care groups were each averaging around a 60% rate of control. When I challenged one of those groups that we should try to participate in this initiative, I was met with at least one response that >80% rate of hypertension control in Loui- siana was simply not possible. The assertion was that we had too much obesity, and the high salt intake in our cuisine would never allow such a goal to be attained. I made the mistake of pointing out that Kaiser Permanente, a large medical group in California that belonged to AMGA, had already attained an 84% rate of control across 600,000 patients — to which I was met with the response, “of course, it’s California, they are healthier over there, they are skinny, they eat right, they exercise … that just can’t happen here in Louisiana.” Six years later, that medical group won the AMGA na- tional award for the best rate of hypertension control in the country, easily exceeding 80%. I used to think that a 90% rate of BP control represented clinical excellence. Now, realizing how easy it is to achieve > 90% rates of control by using a set of easily implemented and exe- ery will be required to impact CKD outcomes significantly, using a patient story as an exam- ple of what is possible. We will discuss how a dream today that envisions better health and outcomes for patients afflicted with CKD will require a bridge to tomorrow that involves changes in how that care is ultimately financed, reimbursed, and delivered to hopefully create a new reality. In Part B, in the next issue, we will delve further into some of the more spe- cific clinical aspects of managing CKD, how disruptive innovation in the management of ESKD is being made possible for providers and health systems who are able to bear actuarial risk for total cost of care, and how new digi- tally augmented support solutions will ensure that clinical interventions are more reliably and equitably delivered across large populations. Today’s Reality End stage kidney disease (ESKD) is the result of the seemingly inexorable progression of CKD, which is not only an extremely expensive disease state, but a growing global concern be- cause of the increasing prevalence of risk factors such as diabetes, hypertension, and obesity. For those patients who are afflicted with CKD, their leading cause of death is not ESKD itself, but rather cardiovascular disease (CVD). Thus far, this entire series of articles on changing the care of chronic conditions has focused almost exclusively on cardiometabolic conditions. Hypertension, diabetes mellitus, dyslipidemia, obesity, and metabolic dysfunction-associated steatotic liver disease are all linked together in what is now being called cardiovascular kidney metabolic syndrome, which was the subject of our last article. Cardiovascular and metabolic derangements have the potential to lead to a more rapid decline in kidney function ac- companied first by subclinical cardiovascular disease, then later by clinically evident CVD in the form of coronary artery disease, heart at- tacks, strokes, peripheral artery disease, atrial fibrillation, and heart failure, all in addition to To some extent, chronic kidney disease (CKD) is an inevitable result of the natural aging pro- cess. In healthy adults aged over 30 years, the average decline of estimated glomerular filtra- tion rate is 1 mL/min/1.73 m2 per year. Esti- mated glomerular filtration rate (eGFR) is our best estimate of kidney function. It quantifies the volume of blood passing through the kid- neys each minute, where the kidneys play the vital role of filtering toxins to be eliminated as waste, regulate acid-base homeostasis, main- tain fluid and electrolyte balance, and help or- chestrate a variety of other important functions. Without functioning kidneys, human life is only sustainable for a matter of days without artificial means of support, also known as dialysis. How- ever, in the absence of other conditions that hasten the decline of our kidney function, we have nothing to worry about because, for most people, our kidneys will maintain their func- tioning status throughout our lives, at least un- til we ultimately succumb to death from some other cause. In a healthy 30-year-old adult with no antecedent kidney disease or other health conditions affecting kidney function, the aver- age eGFR is typically around 90 to 120 mL/min. Therefore, at a decline in function of 1 mL/min/ year, most individuals would have to live to be 120 to 150 years old before this natural age- related decline in kidney function becomes a significant problem. Since the oldest verified age on record ever attained by a human was 122 years, that range of longevity is not a realis- tic expectation for most human beings — espe- cially not within a healthcare system as dysfunc- tional as the one afflicting the United States. CKD is such a complex and nuanced topic that we will divide it into two parts because of its breadth and complexity. In Part A from this issue, we will focus on CKD largely through the lens of its relational interdependence with other chronic cardiometabolic conditions along with the micro and macro landscapes of healthcare delivery. We will explore how radical changes in the structure of care deliv- “Today’s dreams are the bridge to tomorrow’s realities.” – Adlin Sinclair