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- [00:00]
A
Welcome back to Run the List, a medical education podcast in internal medicine. As a quick disclaimer, this podcast is made for educational and informational purposes only and should not be understood as medical advice under any circumstances. Before we get to the show, a quick word on the sponsors for today's episode.
- [00:16]
B
Open Evidence is the premier AI powered medical information platform for physicians and medical students. It's like ChatGPT for anyone who practices clinical medicine. Whether you have a clinical question, a question that comes up during your literature review. If you have a question that comes up when you're trying to synthesize a topic you're going to teach, you can just go to openevidence.com enter your question and it'll synthesize the answer for you while also linking to those actual articles. It's an outstanding resource. Welcome back to Run the List. This is your host, Walker Rudd, and I am excited to be back with Ryan Bonner for part two of our series on chronic kidney disease management. As a reminder, Ryan Bonner is a nephrologist and medical educator here at unc. If you missed the first episode, Ryan and I worked as residents together up at the Veterans Affairs Hospital in Boston. And along the way, during the years I've known him, he has really shared a lot of tips and pearls for the management of ckd, and we summarized a lot of those in the first episode on ckd. But we wanted to record another episode too, and for this one we're going to actually focus on Cardiovascular Kidney Metabolic syndrome or CKD KM syndrome through the lens of chronic kidney disease and how he, as a nephrologist, thinks about this clinical syndrome. We're going to start with a very general and common clinical scenario. Let's imagine we're starting to follow a patient who has multiple risk factors for CKM or cardiovascular kidney metabolic syndrome. Our patient has obesity, hypertension and heart failure with preserved ejection fraction, as well as some other risk factors for cardiovascular disease. All these conditions are broad topics into themselves and we have other episodes covering them in more detail. But today we're really just going to think about these different risk factors within the context of chronic kidney disease. So, Ryan, before we go through each risk factor individually, can you just help provide some overall context for how you understand what CKM syndrome is and how our learners should be thinking about it as they go through their training?
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C
Yeah, absolutely. You know, CKAM is just, it's so, so important. It's this really complex connection overlap amongst chronic eating diseases. You mentioned cardiovascular disease, which has elements of Atherosclerotic disease, but also heart failure, atrial fibrillation, and then also metabolic syndrome, which includes type 2 diabetes, obesity, high blood pressure. You know, it's. CCAM is taking all of these things into account and understanding that there is a link between all of them pathophysiologically. I think for a long time we identified that overlap from an epidemiology standpoint and certainly anecdotally a lot of folks can understand that these things tend to run together, but there's a huge body of evidence now supporting common pathophysiologic background behind all of these. So it's super important to understand that CKD is only part of a larger picture for patients who are experiencing these comorbidities and also understanding that these patients are at super high risk of premature cardiac death and progression of each of these comorbidities.
- [03:27]
B
Thanks so much, Ryan. I mean, just even the way we learn to think about patients, by having a one liner that lists the different problems, by having a problem list in EPIC that has a bunch of different problems, it often oversimplifies things a little bit. And without backing up and taking a more meta approach and understanding the true underlying pathophysiology that's driving all of them together, you can sort of miss how synergistic they can be. So I really appreciate you sort of coming up with this idea for us to focus on it. And now what I want to do is just to review each of the main four individual risk factors. So can you just speak a little bit about risk stratification for atherosclerotic cardiovascular disease, the ascvd, and how you guide your learners to go about calculating it and how it should influence our thinking when we take care of these patients.
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C
So ascvd, again encompasses not just coronary disease, but stroke, peripheral arterial disease, and it's so common in this population. And again, the cardiovascular risk associated with patients who experience the CKM syndrome is just shockingly high. Nephrologists and anyone who's going to be seeing these patients really need to be facile with, you know, the most recent guidelines, the most recent medications, et cetera, to use to mitigate this risk. And certainly part of that in patients who don't have established CVD is getting a sense of what that risk looks like. And you know, the AHA has put out in the last couple of years a new calculator to identify the risk of ascvd, but also heart failure and then both of those diseases together called the Prevent calculator So you get a 10 year risk of either ASCVD or heart failure or both together. And for younger patients you can actually get a 30 year risk to sort of understand that cumulative burden of evolving atherosclerotic disease. And this calculator includes many of the CKM risk factors that we talk about within these comorbidities. Right. So it includes not just things like cholesterol or blood pressure, but certainly their egfr, their urine albuminocratinin ratio. There's so many things that go into patients with CKM and the promotion of atherosclerosis in their vasculature. And this, this calculator helps to try to capture a lot of those things. The value is not just in understanding the 10 year risk of ASCVD, which is included in a lot of guidelines, but also this 30 year risk and understanding again, that cumulative nature of how these comorbidities compound on each other, especially for our younger patients, and including not just ASCVD risk, but heart failure risk as well, given the comorbidities associated with that and how common it is in patients with, with ckm.
- [06:15]
B
Certainly. And I think the point you make there is so well taken that if you're, if you're talking to a patient who's in their 30s and you're trying to help them understand what the risk over 30 years is, if you have an accurate understanding of it as the clinician, you can help inform them the importance of addressing sort of all those underlying factors, at least the modifiable ones is able. So now I know another, another huge part of this is weight management from the renal and from the CKM perspective. How do you think about the management of obesity?
- [06:44]
C
It's incredibly important for nephrologists to be aware of and facile with the treatment of obesity. Lifestyle and understanding how to assist patients with finding a diet and exercise program that works for them is key. Right. That's an important part of managing each of the different components of CKM. Certainly when pharmacologic management is necessary, the GLP1 receptor agonists are going to be the first thing that I reach for. They work particularly well. Right. They address several different components of the CKM syndrome. Right. We knew initially that they address the cardiac element and the metabolic element. And now we have the recent flow trial that demonstrated benefit in slowing the progression of kidney disease in patients with diabetes. So GLP1 receptor agonists really hit a variety of different components of CKM and are really, really valu, of course, for patients where changes in diet, changes in exercise, pharmacological management aren't necessarily achieving the necessary goals. Surgical management, bariatric or metabolic surgery is highly effective, not without risk, especially in patients with kidney disease. But having good relationship with the metabolic or bariatric surgery folks that you work with is really valuable in taking a, taking a collaborative approach with them to find what's really going to help the patient in front of you most.
- [08:02]
B
Yeah, just another example of that multidisciplinary approach. And you know, even if the patient doesn't go on to get a bariatric surgery, it can be extremely valuable to have input from them. And I know they're always happy to at least see the patient and help you think through it.
- [08:15]
C
Yeah, absolutely. And there's actually, in November of this past year, the ASN put out guidance on obesity management in patients with ckd. And it's, it's definitely worth a read and definitely something that nephrologists, primary care docs, cardiologists, endocrinologists. Right. There's so many people who are taking care of patients with ckm. And weight management is something that we can all try to address as able.
- [08:36]
B
No, it's very true. And even on the GI and of course the hepatology side, we're ever more fascinated with these medicines as well. And so basically, whatever you're going into, understanding how you can help walk a patient through not only lifestyle modification, but potentially pharmacotherapy and potentially weight loss surgery or procedures is absolutely critical. The third risk factor we're gonna talk about is hypertension. Now, this is a huge topic, but just again, through the more specific lens of CKM and ckd, how do you think about blood pressure management and what are sort of the guideline, directed goals you want our learners to keep in mind?
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C
Yeah, I agree. I mean, there's so many good episodes of various podcasts and papers out there and things about hypertension. It's certainly deserving of the huge body of evidence and amount of writing that's been done about it. Controlling hypertension is just a huge part of addressing ckm. Generally speaking of addressing CKD and slowing progression, most recent guidelines from KDGO recommended, you know, targeting less than 120 over 80 if possible. With the thought that if you shoot for that goal, you'll end up with folks typically ending up less than 130 over 80, which actually ends up being in a couple other hypertension guidelines. I find that the key piece of monitoring hypertension. Right. Is getting reliable and accurate data. So making sure that patients have home monitoring available to them, making sure that they have instructions on how to obtain accurate, reliable readings are really, really important. Right. There's a lot of education, teaching that goes into this, and I think that ends up paying off in the long run. It's really, really, really valuable. I do tend to aim to keep people less than 120 over 80 if at all possible. Certainly there are folks where the risk of being that aggressive may outweigh the benefits. Right. So thinking about patients with fall risk, orthostasis, autonomic dysfunction, that sort of thing. So at each visit, checking in on patients to make sure that they're taking steps to avoid those symptoms. Right. Getting up slowly, making sure that they're taking it easy. If they do notice any orthostasis, you really want to identify any if it's there, because that may signify. It may not, but it may signify that you need to be a little bit more gentle with your approach. And then there's other situations where, you know, being more aggressive, the benefits well outweigh the risk. Maybe a young person who doesn't have many other comorbidities, but you want to avoid that cumulative exposure to high pressures that can cause progression of their kidney disease, but also contribute to things like atherogenesis and other things. So I think aiming for less than 120 over 80, again with a thought that people will probably end up less than the targets of other available guidelines. And understanding that in patients with long standing, poorly controlled hypertension, that creatinine may go up when you control their blood pressure, and that's a factor of the hyper filtration that you're sort of alleviating by decreasing the pressure that your glomeruli or your filters feel.
- [11:25]
B
Right, That's a great point. And just to summarize, maybe keep the number 120systolic in mind. Like many things, if we strive for that and we come up to short, that's still probably close to where we want to be. Just being really thoughtful and taking the time to talk with our patients, both in terms of understanding their overall context. So you can make individualized decision making and sort of screening for anyone who may be at fall risk, for instance, and then in the absence of that, trying to be as aggressive as you can be safely, and then also just making sure they understand how to get their blood pressure readings at home, how to keep track of this, when to let you know that they're not a goal. Investing that time upfront is really going to save you and the patient in the longer run for our last risk factor. Let's get back to the heart and just talk about the importance of managing heart failure. Again, this is an area that on one hand it seems really intuitive that these things are linked and that we would want to manage it. On the other, it's worth discussing briefly the different medications we have now and make sure everyone's on the same page and sticking with them.
- [12:27]
C
It's really important to acknowledge that the therapies that are evidence based for heart failure through. When you think about your aces And ARBs, your MRAs, your SGLT2s, the importance of using SGLT2s in patients with heart failure with preserved EF as well. Right. There's so much overlap when it comes to medications that are key to preventing heart failure hospitalization and heart failure mortality. Medications that also slow the progression of kidney disease. So, you know, like we had mentioned in the, in part one of our, of these, you know, CKD episodes, there's a lot that goes into not just starting people on these medicines, but keeping them on and understanding things like side effect profile and how to keep patients on these therapies that again, are so important for treating their heart failure or treating their kidney disease. There's a lot that we've said in these two episodes about collaborative care. I cannot say enough about how important that is being able to message the heart failure. Docs, cardiologist who you work with and talk about patients who may be moving a little bit towards decompensation or you think may be eligible for a particular therapy that they haven't been eligible for, that sort of thing is really, really important. And again, with the different components of ckm, right. We've talked about so many different things, so many elements of ascvd, talked about heart failure, talked about kidney disease, talked about obesity. There's, there's so many key pieces of this that nephrologists and anyone who's taking care of patients with ckm, which again is a huge group of generalists and also specialists need to be facile with each piece of these. I certainly don't have the ability to talk about, you know, atherosclerosis and coronary disease in the same way that someone who's cardiology trained can. But I think it's still important for myself and other nephrologists to be aware of and up on, you know, lipid management and other things like that to make sure that we're doing what we can for our patients to reduce their burden of the different components of ckm.
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B
Those are all great points and I just appreciate you taking the time to step through these four different risk factors. Just go through them once more. We thought about risk factors for cardiovascular disease in our patient and then we also thought about how to manage their obesity. We thought about how we wanted to manage their antihypertensive drugs and prevent progression in that domain. And then we also talked about the sort of multimodal therapies we have for heart failure. To wrap us up, Brian, what are your top couple takeaways you want our listeners to remember from today's episode?
- [14:53]
C
Yeah, you know, seachem is made up of so many different components that contribute to excess mortality and in patients and really, really quite common. And a key piece of being someone who takes care of one of these different components is being aware of and somewhat facile with the others. So, you know, while we can't have the expertise of some of our other subspecialists, multidisciplinary care involving those other subspecialists, involving the primary care docs that take care of our patients is really, really, really important. I would say my second take home is just understanding that atherosclerotic cardiovascular disease and heart failure represents such a key intravenable opportunity. So understanding someone's cardiac risk and mitigating that as best as possible using either the prevent calculator on patients with pre existing atherosclerotic disease or other indications for lipid lowering therapy is incredibly important. And then we only briefly touched on it and I think you could probably have a whole episode on it if not multiple. Being facile with the GLP1 receptor agonist is really important in addressing so many different elements, reducing the risk that comes with so many of the different components of ckm.
- [16:01]
B
I just want to take a moment to thank Ryan for joining us and helping share his approach to managing chronic kidney disease and CKM syndrome. This has been great and we really hope you found it as helpful as I did. Thanks to our listeners for tuning in and we'll catch you on the next episode.
- [16:31]
A
Some content from this episode was generated with the assistance of artificial intelligence.