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CME / ABIM MOC

Patient Case: Managing Chronic Kidney Disease and Reducing Healthcare Disparities in Patients With Type 2 Diabetes

  • Authors: Matthew R. Weir, MD; Charles P. Vega, MD
  • CME / ABIM MOC Released: 11/22/2022
  • Valid for credit through: 11/22/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for nephrologists, diabetologists, endocrinologists, cardiologists, primary care physicians, and nurses.

The goal of this activity is for learners to be better able to recognize and address health disparities in patients with chronic kidney disease (CKD) in type 2 diabetes (T2D).

Upon completion of this activity, participants will:

  • Have increased knowledge regarding
    • Health disparities in patients with CKD in T2D


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


Host

  • Charles P. Vega, MD

    Clinical Professor, Family Medicine
    University of California Irvine
    Irvine, California

     

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson and Johnson

Faculty

  • Matthew R. Weir, MD

    Professor of Medicine
    Chief of Nephrology Division
    Department of Medicine
    University of Maryland School of Medicine
    Baltimore, Maryland

     

    Disclosures

    Matthew R. Weir, MD, has the following relevant financial relationships:
    Consultant or advisor for: Akebia; AstraZeneca; Bayer; Boehringer Ingelheim; FibroGen; Janssen; Merck; Novo Nordisk; Vifor

  • Patient

    Disclosures

    The Patient has no relevant financial relationships.

Editors

  • Anne G. Le, PharmD

    Senior Medical Education Director, Medscape, LLC

    Disclosures

    Anne G. Le, PharmD, has no relevant financial relationships.

  • Kim Storck, PharmD, RPh

    Senior Director, Medical Writing, Medscape, LLC

    Disclosures

    Kim Storck, PharmD, RPh, has no relevant financial relationships.

Compliance Reviewer

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

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CME / ABIM MOC

Patient Case: Managing Chronic Kidney Disease and Reducing Healthcare Disparities in Patients With Type 2 Diabetes

Authors: Matthew R. Weir, MD; Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC Released: 11/22/2022

Valid for credit through: 11/22/2023

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Activity Transcript

Charles P. Vega, MD: Why is it that Black or African American individuals make up only 13% of the population but account for 35% of dialysis patients? Or that American Indians and Hispanics are 20% to 30% more likely to be diagnosed with kidney failure? Hello and welcome to season 2 – episode 3 -- of CME-TV: Chronic Kidney Disease in Type 2 Diabetes. I’m Dr Chuck Vega, Clinical Professor of Family Medicine at the University of California at Irvine. This episode is about managing CKD and reducing healthcare disparities in patients with type 2 diabetes.

In previous episodes, we tapped into our inner thespians with a Shakespeare-themed program - “to screen or not to screen” for chronic kidney disease. Definitely check it out. And I promise. I will not talk like that again for the rest of this episode. So far, we’ve learned to screen all patients with type 2 diabetes for CKD at diagnosis and at least annually thereafter, using 2 measurements. One. A serum creatinine test to estimate glomerular filtration rate which is a measure of kidney function. And Two. A urine albumin-to-creatinine ratio to detect inflammation in the kidneys. And most impressively, we’ve learned how to slow kidney disease progression in our patients with type 2 diabetes. So now, when those patients with early stage kidney disease are identified through screening, we can do something to help keep them off dialysis.

But what about those disproportionately affected by kidney disease? Inequities in the quality of healthcare and kidney health outcomes persist throughout the nation. Low-income and ethnic minority patients are less likely to receive care and achieve treatment goals that reduce risk factors for kidney disease. Risk factors like high blood pressure, diabetes, and high cholesterol.

In this episode, we’ll travel to Baltimore to meet Dr Matt Weir, Professor of Medicine and Chief of Nephrology at the University of Maryland Hospital. Dr Weir is a gifted clinician and researcher whose body of work is dedicated to improving the health of patients with kidney disease. We’ll also hear from one of Dr Weir’s patients, Valdez Fisher, Jr. Valdez is a successful businessman, devout husband, and loving father with stage 4 chronic kidney disease and a 25-year history of type 2 diabetes. Well, no time like the present. On the count of 3, let’s go. 3. 2, 1.

I’m delighted to be sitting here with you, Dr Weir. And I’ve brought along a few thousand of my closest friends.

Matthew R. Weir, MD: That’s wonderful. I’m glad you have a lot of friends.

Dr Vega: Honestly, it might just be my parents but let’s get back to the matter at hand. Tell us, what do you think is behind the healthcare disparities in kidney disease?

Dr Weir: There are so many different factors that can contribute to health care disparities with regard to people with chronic kidney disease. Generally, the explanations fall into 1 of 2 categories: higher rates of diabetes and hypertension that lead to kidney disease. Or poor access to insurance and medical care, which leads to delayed diagnosis and faster kidney disease progression. Genetics can play a role, as well. But I like to point out that where people live, learn, work, eat, and receive their medical care are among the greatest determinants of health and health behavior. And these factors are heavily influenced by an individual’s ethnicity, social cultural, and socioeconomic status.

Dr Vega: That makes sense. A person’s ethnicity is a part of their identity and shapes their attitudes toward health, healthcare, diet, exercise, even stress.

Dr Weir: As does socioeconomic status. When you live in a disadvantaged area where you have inadequate access to good foods or there is high crime, which limits your ability to exercise, this can certainly make it more difficult to control your blood pressure, your weight, and, obviously, to control obesity. And if your access to healthcare is poor, it’s more likely that you’ll present late for clinical care, and with even more advanced chronic kidney disease.

Dr Vega: Certainly, that’s very true. Do you think that disparities between communities are reflected on a larger national scale?

Dr Weir: Absolutely. There are many parts of the US where there are disadvantage populations who have much greater risk for kidney disease development. In the Southeast we have many more African heritage patients with very advance chronic kidney disease. We also have problems in the Southwest with Latino populations as well as Native Americans. And this has certainly been well described by the Centers for Disease Control, which has pointed this out repeatedly through the many years that they’ve been tracking the available data.

The other issue that comes up is many of these populations are also overweight. More than 30% are actually obese. Obesity increases the lifetime risk of chronic kidney disease by about 25% compared with individuals with normal weight. These also tend to be the states that I mentioned earlier that have the highest obesity and poverty rates.

Dr Vega: It’s fascinating that where we live – even down to the zip code that we live in -- is one of the most important contributors to our health. But you also mentioned that genetics contribute to disparities in kidney health. How much? And how so?

Dr Weir: Well, we’re learning more and more. For example, we have learned that APOL1 genetic variants arose in people who lived in sub-Saharan Africa because these variants protected against African sleeping sickness called trypanosomiasis.

People with at least 1 risk allele were more resistant to the deadly parasitic disease., inheriting 2 copies of this variant gene significantly increases a person’s lifetime risk for developing kidney failure. We also know that as many as 15%, perhaps even 20% of people of sub-Saharan heritage carry both risk alleles for this APOL1 gene polymorphism. And of those, as many as 20% will develop chronic kidney disease during their lifetime. So that means that as many as 2 to 3% of all people with sub-Saharan African heritage are at risk for developing chronic kidney disease. That's a huge number. In addition, inherited variants in the MYH9 gene are associated with chronic kidney disease and contribute to a substantial proportion of people who develop end-stage renal disease from sub-Saharan Africa. Similar genetic links haven’t been found yet for Hispanics and Native Americans but we’re looking carefully and doing much more research in this particular area.

Dr Vega: By now you’ve gathered that the reasons for disparity and unequal burden are varied and intertwined. Many factors play a strategic role in the causal pathway from CKD risk to CKD development. And Dr Weir has helped to paint a clearer picture of a complicated topic. Take a look at the screen over there. Go on. You can get closer. The risk of developing kidney disease is not because of one single reason. Dr Weir has pointed out that where people live, learn, work, eat, and receive medical care are among the greatest determinants of health and health behavior. And heavily influenced by socioeconomic status and ethnicity. Poor access to insurance and medical care leads to delayed diagnosis and faster kidney disease progression. Diabetes and hypertension are also the most common causes of kidney disease, both of which affect African Americans, Native Americans, and Hispanics disproportionately. And, again, while a genetic variant may put someone at increased risk for kidney disease, other socioeconomic factors are likely to be the trigger for their disease to develop. In other words, a patient’s zip code can be a bigger factor than their genetic code in developing kidney disease. Speaking of zip codes, let’s head back to Baltimore and meet with that patient of Dr Weir’s. Ready. Set. Go.

Valdez! Thank you for joining us. Do you recognize this gentleman?

Valdez: I do. You never forget the face of the man that saved your life.

Dr Weir: Speaking of faces, what’s that fur growing on your face?

Valdez: Old age.

Dr Vega: So, we’ve been talking about healthcare disparities in kidney disease from a clinician’s perspective. But we’d love to learn from your perspective as a patient. Would you mind sharing your story of diagnosis?

Valdez: Well, honestly, I wasn't even aware that I had kidney disease until I met Dr Weir. I had been seen by several different nephrologists but thought it was only for routine maintenance because of my diabetes. Dr Weir was the first person to flat out tell me I had kidney disease. You know, it's interesting, with medical treatment, sometimes a doctor will just start treating you and never definitively tell you that you even have a diagnose to begin with. For example, I have glaucoma. No one has ever said to me, "Valdez, you have glaucoma." They just started giving me these eye drops. And for the longest time, I had no clue that I had glaucoma. Nobody ever said the words to me.

Dr Vega: That’s such an important insight. Perhaps we should all take note. We can’t just assume that patients are aware of all their diagnoses.

So, you go to Dr Weir – and, after having seen a different nephrologist for some time. And Dr Weir tells you that you have kidney disease. Can you share what you remember from that conversation?

Valdez: I can. I was concerned about having to go on dialysis. I was worried about not being able to work anymore….and having to change my lifestyle. In that moment, your mind is racing. You wonder “How bad is the damage?” “How long do I have left?” It was a lot to process. And frankly it still is. But I trusted Dr Weir. Honestly, I really liked the guy. I liked him immediately because he's a straight shooter. He told me flat out, "The path you're on, this is what's going to happen to you." And a guy like me needs to hear that. I really do. I don't need passive treatment. It doesn’t work for me. I wasn't always the most compliant patient. But -- more importantly -- he told me specific things that I could do to slow the progression. And to focus on things like my weight, my blood sugar; things I've wrestled with my entire adult life. It's very difficult to do, but it is manageable.

Dr Weir: And he was all over it. Started managing his blood pressure, his blood sugar, and focused on really the 3 big issues that we had discussed for slowing the progression of his kidney disease and that is his blood pressure, his cholesterol, and glucose.

Valdez: Well, I understood that if I didn’t, the only other option was to start looking for a kidney. And I don’t know about you guys, but frankly, I’m a little fond of my own.

Dr Vega: I think everyone is fond of their own kidneys. That’s great insight. Thanks very much. Had you ever encountered kidney disease prior to your own diagnosis?

Valdez: Personally, I have not, but I've known a few dialysis patients, and I never knew what got them in that posture. I just knew that they had to go someplace a couple times a week and come back like they'd been run over by a truck.

Dr Vega: Yeah, I’ve seen that same thing. And it’s interesting. 9 out of 10 Americans don’t know they have kidney disease. Just like you weren’t aware until you met Dr Weir. How do you think that the medical community can reduce disparities in the diagnosis and treatment of kidney disease?

Valdez: There is no argument that systemic change is needed. Availability of care. Lack of transportation. But in the interim, I’d say making sure that every patient with diabetes is tested for kidney disease would be an excellent start. It’s so important that people are made aware of their risk. Especially in communities of color where there’s a disproportionate amount of diabetes and kidney disease. 

Dr Vega: This is such an important point, Valdez. So many patients are not aware that they have reduced kidney function, which makes it critical that every type of primary care provider screen for kidney disease by assessing GFR and urine albumin-to-creatinine ratio. That's the most objective way to identify patients at risk.

Dr Weir: That’s true. In nephrology, we still see a lot of people coming in very late in the course of kidney disease. In fact, many of the patients have lost more than half, if not 80 to 90% of their kidney function. And at that point, the horse is out of the barn. There certainly are therapies we can use to slow the progression, but you’ve already looking at people who will require a kidney transplant or need to consider starting hemodialysis. So, I couldn’t agree more. The earlier the identification. The earlier the education. The earlier the intervention. The more likely you can preserve kidney function and delay the onset of end-stage renal disease.

And we’ve seen all these models work before. The Indian Health Service cut the rate of kidney failure by 54% for Native Americans with diabetes using population-based interventions to prevent disease and promote health. In general, the approach was straightforward. But upstream interventions occurring well before kidney failure were necessary including routine screening for measuring GFR, blood pressure, glucose control, and, of course, prescribing renoprotective medications when indicated, and providing educational outreach to both patients and the healthcare providers. The data you see here are the result of consistent implementation of these interventions over the past 30 years. uACR was assessed for 62% of Native Americans with diabetes aged 65 and older. Blood glucose control improved by 10%. Average blood pressure improved to 133/76 in Native Americans with diabetes and hypertension. And the use of renoprotective medications increased from 42% to 74% over a 5 year period.

Dr Vega: Those are really impressive and necessary results. And speaking of timely diagnosis and treatment, recently race was eliminated as a factor in assessing kidney function, because unfortunately, it led to an overestimation of GFR, delaying diagnosis and treatment in the Black population.

Dr Weir: That’s right. The American Society of Nephrology and National Kidney Foundation now recommend the use of the 2021 CKD-EPI creatinine equation which estimates kidney function without a race variable. We are now classifying more people with kidney disease than we did before, and treating them earlier, which means we’ll see future benefits.

Dr Vega: Fantastic. Well, gentlemen, unfortunately, our time is coming to an end. And the kind folks who’ve been listening out there need to get back to their day.

Valdez, anything else from your experience that you’d like to share with our audience?

Valdez: Well, I would like for doctors to understand that a relationship with their patient is very, very, very important. And the reason I say that, it may sound cliche, but if you have a good relationship with your patient, then a patient is more apt to be upfront and honest with you. Dr Weir is very straightforward. That's the reason why I trust him. I mean, if he told me it was raining bricks, I’d come outside with a hard hat.

Also, doctors, empower your patients. Help them understand the stage of their kidney disease. It is because Dr Weir shared this information with me that I understand the severity of my disease. I knew what I needed to do. And I was able to see my numbers improve. I could see that by doing the things he asked me to do – changing my diet, exercising more, taking my medications – all of those things slowed the progression of my disease and kept me off dialysis. I cannot stress enough what that has meant to me. What it continues to mean to me. And what it would mean to countless others as well.

Dr Vega: More sage advice from someone with intimate knowledge of the importance of early screening, education, and intervention for chronic kidney disease. In this episode, we’ve learned that as health professionals, it’s important that we’re aware of healthcare disparities and how social determinants of health influence health outcomes. It’s also critical that we understand the diversity of the patient population we serve. We’ve also learned that screening at-risk patients for CKD and treating CKD in the context of comorbid conditions such as diabetes, hypertension, and cardiovascular disease has the potential to reduce disparities and the risk of progression to end-stage renal disease.

We encourage you to visit episodes 1 and 2 of this series where the practical application of screening and treatment are discussed in detail. But first, please continue on to answer the questions that follow this episode and complete the evaluation for your CME credit. On behalf of Dr Weir, Valdez, and myself, we’ve enjoyed spending this time with you. Please be sure to check back to discover the revelations of new data released in 2022 in our final episode, “Updates on Clinical Use of Non-Steroidal Mineralocorticoid Receptor Antagonists in the Management of Chronic Kidney Disease in Patients with Type 2 Diabetes.” Alright, last time, I promise. 3…2…1.

This transcript has not been copyedited.

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