Making Early CKD Detection Count: Ralph Riello, PharmD, and Nihar Desai, MD

Early detection of chronic kidney disease (CKD) means little if it does not lead to timely treatment, yet a significant gap persists between when CKD is found and when evidence-based therapies are started. That disconnect is the focus of the second episode of Beyond the Silo: Integrated Care Across the CRM Continuum, a podcast series from The American Journal of Managed Care^®, in which Ralph Riello, PharmD, BCPS, leads a conversation with Nihar Desai, MD, MPH, on how to shift CKD care from a reactive, late-stage model to one that is proactive, pathway-driven, and equitable.

Riello is a clinical pharmacy specialist focused on cardiorenalmetabolic disorders at Yale School of Medicine. Desai is a cardiologist, clinical investigator, and vice chief of the section of cardiovascular medicine at Yale, where the 2 collaborate on research and quality initiatives aimed at improving CKD management across the care continuum.

The discussion builds on the first episode's focus on urine albumin-to-creatinine ratio (uACR) underutilization, stipulating that screening has occurred and asking what must happen next. The experts argued that once an elevated uACR result is in the chart, providers across all specialties, not just nephrologists, must be empowered to act on it. With roughly 1 nephrologist for every 2000 patients with CKD, waiting for a subspecialty referral is not a workable solution. Primary care physicians, cardiologists, and endocrinologists all have a role in initiating guideline-directed therapy.

On the treatment side, the evidence base has expanded considerably. Sodium-glucose cotransporter 2 inhibitors now carry strong data across heart failure, atherosclerotic cardiovascular disease, and CKD independent of diabetes status. The nonsteroidal mineralocorticoid receptor antagonist finerenone adds renal and cardiovascular protection in patients with CKD and type 2 diabetes, and dedicated trial data support combining the 2 classes. Glucagon-like peptide 1 receptor agonists round out a growing armamentarium, but uptake remains well behind the evidence.

Desai and Riello were candid about who is most at risk of being left behind. Disparities in screening, diagnosis, and treatment initiation persist along lines of race, sex, geography, and insurance status, and the shift toward branded therapies adds new cost and access barriers that require active advocacy at both the clinical and policy levels.

"The stakes are very high; the urgency is very real," Desai said, a phrase he returned to throughout the episode. "It's not a problem of resources, or that we don't have the science, or that we don't have the therapies—because we have all of those. It's finally about taking that next step and delivering for our patients."

The episode closes with a call to action for frontline clinicians: commit to uACR testing, learn the staging framework, and initiate the therapies that the guidelines already recommend. As Desai put it, the question for every provider is straightforward: “What can I do tomorrow in my practice that I didn't do today?”

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