Today on the podcast, we talk with Rebecca Grandy, Directory of Pharmacy at CHESS Health Solutions, about the connection between diabetes and chronic kidney disease, the populations who are at risk, how to address any concerns, and what tests and interventions are available to the provider.

OK, so, Rebecca Grandy, welcome to the move to Value podcast. Could you start by explaining the connection between diabetes and chronic kidney disease and why it's so important to screen for these in diabetic and or for chronic kidney disease in diabetic patients?

Sure. You know, diabetes is one of the leading causes of chronic kidney disease. I think there's lots of reasons for that. A lack of early screening, a lack of just knowing what to do, having accessible medicines. But all of those things now we have relatively good screenings, we have medications and so kidney disease and diabetes is present preventable. And then just from a, you know disease, state perspective, diabetes itself, the high glucoses, the inflammation on the high blood pressure, obesity, all of those things also increase your risk for chronic kidney disease and so you'll see a strong correlation between those two.

And you know, it's also proven that minorities are disproportionately affected by chronic kidney disease and what steps do you think can be taken to address that as we start looking into our social determinants and our HealthEquity components of the quintuple aim?

Wow, that's sort of a can of worms type of question, right? Because you know, when I think about minority populations or even just disparities in healthcare, I think there are lots of reasons for those. One is access and so primary care I think is the solution for that. And so being able to solve access issues to primary care, there are also issues like social determinants of health issues and so thinking through a lot of the work that ACOs are doing, like the REACH model, care coordination, social work, really being able to not only screen for social determinants of health, but to actually have solutions for those. And so I think that's happening slowly. You know, those screenings are starting to be incorporated into primary care, but if we can address some of those issues, I think we can solve access issues. The harder one in my mind to solve is sort of the historical like trauma and distrust that comes with minorities in the healthcare system. That one's harder, but I think. I think you know having minorities go into positions where they are providers, right? So I can see someone who culturally is like me, who looks like me, who I know has my best interest at heart. I think a lot of those pipelines for minorities to be healthcare providers, are really helpful as well.

Yeah, I think that's definitely true. So some of our data at CHESS shows that you know up to 40% of people with diabetes do develop chronic kidney disease. Can you explain why early screening is so critical and how it impacts the progression of that disease?

And I feel like I have to tell a story first. So, you know, when I was working in primary care, one of the most, I don't know, frustrating's the right word, but definitely discouraging things is when you see someone sitting in front of you that has a chronic condition that could have been prevented, right? And I feel like chronic kidney disease is one of those preventable conditions because when you have chronic kidney disease and you progressed in stage renal disease and you're on dialysis that kind of takes over your entire existence, right? Like those people are going to dialysis three times a week, you have to be really careful about the nutrition, about your protein intake. You have to be careful about all your medicines. You can't just go to your cabinet and reach for your ibuprofen. And so the fact that something that you know can be so significant or impact your lifestyle that much is preventable. Like I feel really passionate about that. And so when we think about screening is actually one of our quality measures now for a lot of our contracts, especially with Medicare Advantage, but it's called KED and that's the kidney health evaluation for people with diabetes. It involves two different tests, so you have to get a blood test. Most practices and physicians offices are really good at this piece. It's part of routine blood work. Like if you have your basic metabolic panel or CMP, it's part of that. You're looking specifically at your creatinine and your EGFR, or that estimated glomerular filter rate and that's just kind of looking at the kidneys to see. Are your kidneys actually able to filter out waste or toxins out of your body? Again, primary care providers really good at getting that piece. Blood work. The piece that I think we struggle with that's equally important is actually you need a urine sample as well. And so in the urine sample, what you're looking for is you're looking for protein in the urine because that is not normal. To have protein in your urine, and that's called the UACR or urine albumin creatinine ratio. And that again, that's just looking to see if you have protein in your urine because that indicates that your kidneys are potentially damaged and they're sort of leaking, if you will. And so those two things are really early indicators that can tell us if someone's at risk. For chronic kidney disease, cause in general in the beginning, chronic kidney disease doesn't really have symptoms. It's silent and I think I read a statistic somewhere that 90% of people who have it don't even know they have it. In the beginning, there are literally no symptoms, and so you have to screen to be able to identify it.

So one of the one of the big challenges that the practices face is getting the urine test that that could be is that the most difficult when you your assessment?

That's what. Yeah, that's what I found in my experience. Like, I think that's sort of been multifactorial. Probably really two factors that play into that. You know one, you're the primary care provider, you have a patient coming to you and they may have five different problems they want to talk about I'm guilty of this, right? Like I save up my problems and I want to talk about all the things when I get there. And so you're sitting in front of this person who may have very different priorities than what you think you want to do, or labs that you want to do. So, by the time you're finished addressing what you can address with them, you've just forgotten. About it, right. And so, unless it's really part of the process or standard of care, it's easy to forget about. So, my thought would be everyone needs to have sort of a standard operating procedure around diabetes, if you will, right? You're gonna get their blood pressure. You're gonna get their A1C. We need to start making those urine screenings part of that sort of standard process, you know, allow your team members to help you. Doesn't have to be the provider, it can be the staff. It can be the lab. You can have standing orders, but it really has to become a process issue or it slips through the cracks. So I think that's one of the biggest things. The other thing that I've also experienced in primary care, and so this measure used to be a quality measure many years ago and it was It was slightly different than the one we have today, but I would often hear providers say, well, my patients already on an ACE inhibitor or an ARB, those are the medicines that we use to help protect the kidneys. The oldest medicines we have. So like, why should I? continue screening that's just a wasted test. We are in a very different situation now with some of the medications we can use to help protect kidneys. So, I think part of that piece is just education around those medicines and how to help patients get those medicines.

That's awesome. Do you, when it comes to preventing kidney disease, what lifestyle changes and interventions do you typically recommend for patients with diabetes?

Yeah, I mean, and the lifestyle interventions are really the same ones that we would recommend to anyone to keep them healthy. You know, part of comprehensive care. So we're going to recommend that people, you know, try to maintain a healthy weight. If people are obese or overweight, that comes with insulin resistance. Insulin resistance comes with inflammation. And so that can lead you into damage to the kidneys down the road. High blood pressure. You know, if you have high pressures that's going to be in your kidneys as well. So that high pressure in your kidneys can damage your kidneys, so you're going to try to manage your blood pressure through maintaining a healthy weight. Exercise and nutrition, right? Things we all should be doing and then a huge one is smoking. So smoking has quite the effect on the kidneys too, because of the inflammation and just changes that happen to like your vascular system when you smoke. And so the kidneys are highly vascularized. And so anything that can affect you know, your vascular system. It's gonna affect your kidneys. So same things we all should be doing. Don't smoke. Maintain a healthy weight exercise and try to eat right.

Those are sometimes the hardest things to do.

I know, right? If it were easy, we would all do it. That's what I tell people. If it's easy, you would have done it already.

I'm really glad we're having this conversation. So can you tell me what a typical screening process looks like for for kidney disease? Walk us through the tests like the EGFR and the uacr and explain their significance. You touched on it a little bit, but you know what does that look like?

Yeah, sure. And so, you know, if I'm a patient coming into the office and I would empower patients to do this as well, right? Like part of, you know, taking care of your own health is being proactive and being an advocate for yourself. So if you happen to be a patient listening to this or you know someone who has diabetes, I always encourage people to make a list of all the things you want to make sure you have done and kidney health is one of those. But also thinking about. Your eye health. Your feet. You know your eyes. Your kidneys, your feet are always things you want to think about when you have diabetes. But for your kidney specifically, most patients are going to have blood work. So, they'll get a blood draw once a year through that blood work, they can calculate that EGFR again, it's calculated in mils per minute. It's mainly just like how much blood your kidneys are able to process and filter. Your kidneys are kind of like a filter, just like your car has a filter right with oil and your oil filter in your car is filtering that oil to make sure all the toxins are taken out. That's exactly what your kidneys do. And so that's what that blood test looks at is how well are your kidneys filtering? And then you're literally gonna have a urine sample taken, right? So nothing invasive about that. And when you have that urine sample taken, what they're looking for is protein. Protein in your urine is not normal. There are some things that can cause it to be temporarily in there, like intense exercise. If you have really high blood sugars. Infections like if you have a urinary tract infection. So sometimes you can't have protein in there. And it's just transient. It's going to go away. So anytime you have a urine test and they detect protein in it, you're going to want to get a recheck in three to six months to make sure that protein in there is persistent. That's one of the pieces I find in primary care that's the hardest, even if they do the initial one, confirming it again in three to six months can be really hard because again, you have someone coming in just for the purpose of getting the urine sample and that is looking to see, you know, if your kidneys or if that filter within your kidneys is leaky, should not be leaky, right? It should be there should be no protein getting into your urine, and so that's what that's looking for. Both of those tests in conjunction can tell you if you have early stages of kidney disease and what we need to do differently.

Interesting. I never thought about leaky kidney filters before, but that makes sense. I like that.

Yeah.

So I've heard you talk about other treatment options for kidney disease that are that are being used now more so than in the past? And could you elaborate a little bit more about these newer treatment classes and how they differ from some of the older therapies?

I think, and I think this is one of the most exciting parts of this conversation. You know, we should definitely be screening early because it's preventable, but now we have way more medications than we used to have in the past. So some of the early medicines like I alluded to where your ACE inhibitors and ARS medicines historically used for blood pressure, right? So they're your lisinopril's, your Losartan, prils and arten's. That's how you know. And we've had those for a long time. Now we have other medicines that have been shown specifically to protect the kidneys. So there's two groups of those in the diabetes group of medicines. So one is sglt 2s. Those are gonna be your medicines. Like INVOKANA, Farxiga, Jardiance, they work actually, by helping your body get rid of glucose through urination. That's part of what our body does anyway, but they lower the threshold. As part of that process, they also lower the pressure, if you will, inside our kidneys. They also decrease inflammation, so they have a lot of good evidence, these particular medicines, that they can prevent progression of kidney disease. And I have to give a shout out to my VA colleagues. I'll say these medicines work so well, even though they're expensive, this year, and this coming year it's been a focus of the VA to make sure that everyone with these early signs of chronic kidney disease actually get these medications. And if they're not getting them, there has to be a documented reason why. So I think the fact that our, you know, healthcare colleagues in government you know see the benefit of these and the cost effectiveness of them should really. Make a case for them for the rest of our audience as well, who are in the private space. So that's a really exciting group. So if you have patients that have some degree of chronic kidney disease, you should definitely be looking into those medicines. Our GLP 1S, like Ozempic, Victoza, Trulicity, Mounjarro you know the ones that are popular because their weight loss benefit. They also have some early evidence in kidney disease and preventing that progression as well. They work by decreasing inflammation. They have lots of ways that they work, but that's one of the most common ways. So especially if someone wants to lose weight, they have cardiovascular disease. And they have some early signs of chronic kidney disease. Those medicines can be a nice choice. And then now we even have a fourth class of medicines that we haven't had before. There's one called phenerinome. If you're a primary care provider or even a patient listening. This is very similar to spironolactone, which we've used for a long time, except this particular medicine is more selective, has less side effects, and has clinical trials to decrease chronic kidney disease. So there are a lot of options. I mean, we could spend, you know, a whole just discussing the medicines at this point.

Yeah, this is wonderful, Rebecca, because I, as a consumer of media. we're remote. We both work from home and so because of our work, our Internet usage, especially mine now involves a lot of healthcare research. And so I also have streaming services for my television. And so my family gets a little disgruntled at these wonderful ads for all of the medications that come in because I'm obviously in the demographic where I'm super sick, I have diabetes. I have heart disease. I have all of these other quality measures that need to be addressed because we're writing about them in marketing and communications, and they do have some wonderful commercials. And I have learned a lot about that. All of the names that you've mentioned, it's really funny because as you're mentioning them, I can I can visualize my head, these, these, these ads which says a lot about we could talk about media consumption and how this impacts the consumer's choice but that's for another conversation. But it was really interesting when you were talking about this, how I in my in my brain, I could hear almost hear the song. I digress. So but as we talk about these, these newer treatments, of course they, they come at a cost and there's often a concern about this cost. So how would you advise clinicians to navigate this when prescribing these medications to patients? You mentioned the VA, but what about those who perhaps fall into the cracks?

Sure. I mean, you know the first thing is you just need to acknowledge that medicines are expensive and ask about the cost, because I think that takes away some of the shame and stigma that come with not being able to afford your medicines that our patients experience and there, I think we've talked about this on a previous podcast, but there's evidence that says, you know, 2/3 of patients aren't sharing the fact that they're having trouble affording medicines with their providers. So I think having that open non judgmental like hey, I'm going to put you on this medicine. It's expensive. Your insurance should cover it. However, let me know if it doesn't and then when they follow back up like hey, I know I started you on this medicine. I know it's expensive. What trouble did you have getting it, you know, were you able to afford it? Trying to be as open-ended as possible, so that would be the first step is just to ask the question and acknowledge that these medicines are expensive. The second step to that in my mind is there are lots of resources to help with affordability that patients don't know about, providers don't know about and they may be hard to navigate and time consuming. So, the local ship counselors in North Carolina, S-H-I-I-P. Those are folks that are funded actually through some grants that can help patients specifically with Medicare navigate which health plans are best for them based on their conditions based on their medications. They can also tell you if you're eligible for something called low income subsidy or extra help that can significantly decrease the cost of your medicines, but also the cost of your premiums, so that's where the second bucket that I recommend is looking to if they're eligible for extra help or low income subsidy. And then the third bucket, if that one doesn't work, there are patient assistance programs that we can sign patients up for through manufacturers. So in my experience, through one of those different avenues, we are usually able to get the patients, the medicines that they need and the medicines that the providers you know, think are right for them.

Yeah, that's good. That's good advice. So, but if a patient's condition continues to progress despite all of this, what would be the next steps in intensifying their therapy? Like what role would you know, we talked about lifestyle modifications, but when we talk about, you know, a pharmaceutical interventions for blood pressure control and statins, how do they play in this process?

Yeah, sure. And you know, like I said, we have several classes of medicines that are synergistic and can be used together. If you look at the ADA, the American Diabetes Association guidelines, they're really nice charts that can walk a provider through how you