HJNO May/Jun 2024

CHANGING THE CARE: CHRONIC KIDNEY DISEASE 28 MAY / JUN 2024 I  HEALTHCARE JOURNAL OF NEW ORLEANS   cuted clinical and operational processes, I now believe that 90% rates of hypertension control are simply the standard of care. True clini- cal excellence is now in the 96 to 99% range. In the year 2016, the AMGA launched an- other initiative known as “Together 2 Goal,” which was their campaign to improve rates of diabetes control (meaning the percentage of patients achieving hemoglobin A1c < 8 mg/ dL). There again, I used to think that achieving a 90% rate of control represented clinical excel- lence. Based on my experience in being able to achieve 96 to 99% rates of control for diabetes mellitus, I now also believe that a 90% rate of glycemic control should also just simply be the standard of care. These are important consid- erations, because when we achieve these levels of control across a population concomitantly, we are indeed slowing the decline of kidney function over time, albeit with the contention that how we achieve these results matters a great deal. Staying up to date with the latest research and understanding the nuances of how certain medications work, when to hold them, when to restart them, and ensuring that there are established processes in place for ac- curate timing of laboratory monitoring of ap- propriate variables are essential to maintain optimal outcomes. In other words, as it relates to CKD, slowing the inevitable deterioration in kidney function becomes a product of how well we are managing the conditions that hasten its progression. But true clinical excel- lence in the management of CKD, and there- fore widespread improvements in health, will only be realized when rolled yield calculations of control rates are happening concomitantly, meaning that we are achieving multiple tar- geted goals in the same individual at the same time and doing that reliably and consistently across a large population. And as mentioned in previous articles, the advent of digitally aug- mented support solutions will need to be em- braced and implemented to adequately scale the delivery of this level of clinical excellence. We now have objective scores that predict how fast a given individual’s kidney function might deteriorate. The kidney failure risk equa- tion (KFRE) uses a set of easily measured vari- ables to predict the two-year and five-year risk of kidney failure where dialysis may become necessary to sustain life. The variables used in this formula can include age, sex, eGFR, serum level of creatinine, urinary albumin-to-creati- nine ratio (UACR), presence of diabetes, pres- ence of hypertension, history of CVD, race or ethnicity, and smoking status. UACR deserves special mention here. Albuminuria refers to the loss of a protein found in the blood known as albumin, which, due to compromised structural integrity within a microscopic structure in the kidney known as the glomerulus, can become freely filtered into the urine. Measuring and quantifying its presence in the urine becomes an important predictor of the degree of kid- ney damage. Small amounts of albumin in the urine used to be called “microalbuminuria,” which is now an outdated term. Instead, the more up-to-date terminology is to refer to the degree of albuminuria as mildly increased (0 to 30 mg/g Cr), moderately increased (30 to 300 mg/g Cr), or severely increased (> 300 mg/g Cr). Creatinine is a substance that is freely fil- tered across the glomerular membrane, and, therefore, measuring the ratio of albumin to creatinine becomes a very important objective assessment of how much damage is present, which is in turn indicated by disproportionately increased amounts of albumin to creatinine across a structurally damaged membrane. Fre- quently measuring UACR at specified levels becomes important, along with concomitantly controlling the chronic conditions that dam- age the glomerular membrane and increase UACR. Decreasing UACR directly impacts an individual’s KFRE score (i.e., their risk of kidney failure) and becomes a function of adequately controlling such conditions as diabetes and hypertension. The unfortunate reality of to- day is that most health systems and providers are nowhere close to achieving rates of >90% control of the chronic conditions that impact the rate of progression of CKD. It does not mean that we have a bunch of bad providers and health systems, but it does mean that we have some flawed processes and systems that act as barriers impeding the progress of turn- ing today’s dreams into tomorrow’s realities. Today’s Dream But first, to illustrate how all these conditions and variables are linked together, I would like to use a real-life patient example to help clar- ify understanding of how our ability to modify these conditions and variables could lead to dramatic improvements in the incidence, prevalence, and rates of progression of CKD. My initial encounter with a now 60-year-old so- cioeconomically disadvantaged Black woman was on Nov. 19, 2021. Her previous care provid- ers may have labelled her as “noncompliant” and blamed the extent of her disease burden on her own health behaviors rather than on a structurally flawed care delivery model. My first encounter with her took place in a special clinic that is “architecturally” designed to treat mem- bers of our self-insured employee health plan. Self-insured means that we, the employer, bear the actuarial risk for total cost of care related to our health plan member expenditures, which are primarily those of our own employees and their dependents. Being self-insured gives us tremendous control over the design of their plan benefits and in the design of the care mod- el utilized to effectuate health outcomes. At the time, this patient’s prior two hemoglobin A1c’s were > 14.0 and 11.2 with her last several A1c’s never reaching single digits. She was referred to our clinic by our endocrinology department. Her eGFR was 48 mL/min with a urine albumin- to-creatinine ratio (UACR) of 1217, indicative of severely increased albuminuria and an ominous prognostic sign for her CKD. Her LDL was 141, and she had only recently been prescribed a high-intensity statin. Her 10-year risk of a major adverse atherosclerotic cardiovascular event as indicated by her ASCVD risk score was > 40%. Her blood pressure during that office visit was 180/102. She was on a proton pump inhibitor for chronic gastroesophageal reflux disease, which was in turn exacerbated by her obesity. Her two-year and five-year risk of progress- ing to overt kidney failure as calculated by the KFRE was 5% and 14.4% respectively, meaning that she had at least a 5% chance of requir- ing dialysis in two years and a 14.4% chance at five years. She also suffered from diabetic- induced peripheral neuropathy in her feet with numbness, tingling, and pain that was worse in her right foot. She recounted an episode two years earlier where she reported her right leg “felt like a piece of wood, I couldn’t feel any- thing, when I would stand it was just like Jell- O, I just couldn’t stand on that leg,” which resulted in an ER visit. She was told that it hap- pened because her “sugar was just too high.”