Ryan Haumschild, PharmD, MS, MBA: One thing that we talk about is that CKD [chronic kidney disease] for a while didn’t get a lot of attention. And not to say that it’s not popular, but there weren’t a lot of therapies, there wasn’t a lot of awareness around it. And we feel like it’s continued to trend upward, as we heard earlier from Dr Nicholas. So, Dr Anderson, we know CKD gets a lot of attention with [patients with] end-stage renal disease. And when we’re discharging patients or they’re coming in for a hospital visit and we start to recognize their uACR [urine albumin-creatinine ratio] is out of range or their serum creatinine, should we be thinking differently about these patients? Do we start something on discharge? Do we think about a workup for a patient? Why is it important for CKD to be managed and treated in earlier stages and [why is it important for] us to think differently about the disease than we traditionally have in the past?

John E. Anderson, MD:Well, I think you’ve heard multiple reasons why we need to be getting these patients, both young in their disease course and young in their age, on guideline-directed therapy early on. And one of the great conversations that is happening right now in the hospitalist community is identifying gaps in care. Someone comes in with an elevated uACR plus or minus an elevated lower eGFR [estimated glomerular filtration rate]. There is no reason they shouldn’t be started on an initial T2 inhibitor during their hospital stay and have a prescription written as they exit the hospital. One of the great faults—and we know this—[lies in] that transition of care from the hospital back to the primary care clinician. Now, I happen to have all of the information because I’m at the hospital, even though I don’t do hospital work anymore. I have all the information that I have when I have that follow-up visit. But that’s not so true sometimes in rural communities when they come from a hospital that’s not in the system or they don’t have access to the medical records. Again, there’s nothing wrong with picking up the phone and calling the clinician and saying, “Hey, your patient just got discharged from the hospital for whatever reason. But here’s what we’ve identified and here’s a gap in care. So they’re going home on this SGLT2 inhibitor at this dose, and they have enough for another 2 weeks until they see you. But I want to let you know that, and we’ve let the patient let you know about the follow-up so we can continue this therapy.” Maybe true for GLP-1 receptor agonists as well. So hospital transition is a great place to try to identify these patients and treat them early. But again, going back to breaking down the silos of care, anybody who has a touchpoint with that patient, whether it’s in the hospital or anywhere else that’s identifying a gap in care, needs to address the gap in care. And that doesn’t mean they have to address it themselves. For example, if a cardiologist puts a stent—[or] 2 stents in a patient—now this is a type 2 patient who has atherosclerotic cardiovascular disease, there’s guideline-directed therapy that suggests GLP-1 receptor agonist ought to be started. Well, they may not have samples in their office. They may not have the ability to talk to them about how to mitigate [gastrointestinal adverse] effects like we do. Same thing with an SGL-2 inhibitor. They may not have nurses who are used to prescribing things like mycotic infections, whereas we do that all the time. So I don’t care that you start it or you give the first dose.… And then if it’s back to me or if it’s back to the endocrinologist, let us identify that gap and we can be the ones to start it. It’s all about communication.

Ryan Haumschild, PharmD, MS, MBA: You really hit on those transitions of care. And I feel like there are so many gaps right now.… Even when we talk about the hospital, maybe some heart failure or cardiovascular physicians, we’ll start an SGLT2. But if they start to see the trends of looking at CKD, you don’t always see that started or you do not see that started upon discharge or handed off to a colleague who might be able to treat that patient…and do a better, more comprehensive workup. Great comments and I appreciate you. Dr Nicholas, when we talk about the guidelines, how have they kept evolving in recent years? I made a comment earlier that there weren’t a lot of changes in CKD, but we know that there have been now. So talk to us about that and what are some of the recent changes in these guideline-directed therapies and screenings?

Susanne B. Nicholas, MD, PhD, MPH: Absolutely. And we’ve touched on some of this already, maybe not in specific terms, but I do want to extend something that Dr Anderson has recently touched on. It’s not only about filling those gaps and transition of care when a patient is discharged or when they’re in the hospital to start them on SGLT2 inhibitors or standard-of-care RAAS [renin-angiotensin-aldosterone system] inhibitors, we actually did a study to look at sustaining guideline-directed medical therapies over time, and we observed again from our chronic kidney disease registry that patients who are on RAAS inhibitors at baseline could be as high as 70%, but within 3 months it’s declined [to] about 40%. That’s a huge gap. And similarly, if you look at patients who are starting SGLT2 inhibitors, they’re not sustained. But what we do know is that the results of these studies require these medications to be on board long term to actually have the optimal outcome benefit. And so it’s important—it’s not only about writing that initial prescription but following up with your colleagues to see these medications…refilled. So with that as a foundation, it also touches upon the changes in the guidelines. Now the KDIGO [Kidney Disease Improving Global Outcomes] guidelines [have been around] since 2003. In 2012, we provided that KDIGO heat map that we talked about earlier and what is recommended for the care of patients with CKD in more recent times. What has changed is that multidisciplinary care team and the requirement of that team that we’ve talked about, each of us really has mentioned this at some level, but it’s written in the guidelines. It’s not just about having the silos of specialty care, whether it’s the PCP [primary care physician] or the endocrinologist. It’s really [important that] everyone who is relevant to the care of that patient be on board and participating in the care of that patient in a team-based approach.… It’s not simply about looking at chronic kidney disease. Cardiovascular risk is incredibly important. Those have been the changes where the focus has shifted now to be more…comprehensive.

Ryan Haumschild, PharmD, MS, MBA: I think that comprehensive view, that collaboration, identifying those comorbidities [will] be key to early intervention with these patients. And really, like you said, looking beyond just CKD in a silo.

Transcript is AI-generated and edited for clarity and readability.