1
00:00:02,120 --> 00:00:06,000
Welcome to this episode of KD Go
Conversations and Nephrology. 

2
00:00:06,400 --> 00:00:11,520
This episode, titled Applying 
CKD Interventions, is provided 

3
00:00:11,520 --> 00:00:15,960
by KD Go and is supported by an 
independent educational grant 

4
00:00:16,239 --> 00:00:19,880
from AstraZeneca. 
Here's your host, Doctor Peter 

5
00:00:19,880 --> 00:00:22,970
Lynn. 
Hello and welcome to Kate Eagle,

6
00:00:22,970 --> 00:00:26,050
Conversations in Nephrology. 
I'm Dr. Peter Lynn, Director of 

7
00:00:26,050 --> 00:00:28,530
Primary Care Initiatives at the 
Canadian Heart Research Center 

8
00:00:28,530 --> 00:00:31,090
and a family physician in 
Toronto, Canada and joining me 

9
00:00:31,090 --> 00:00:34,690
today to discuss the importance 
of applying CKD interventions. 

10
00:00:35,030 --> 00:00:37,910
Is Dr. Joel Toff, who is an 
Assistant Clinical Professor of 

11
00:00:37,910 --> 00:00:40,710
Medicine at Oakland University 
William Beaumont School of 

12
00:00:40,710 --> 00:00:42,870
Medicine. 
But Joel is really famous for 

13
00:00:42,870 --> 00:00:46,830
his Twitter account Kidney Boy, 
where he discusses all things 

14
00:00:46,830 --> 00:00:49,030
kidney. 
He is also the cofounder of Nef 

15
00:00:49,030 --> 00:00:53,270
Madness and NEF JC a Journal 
Club, and he's also the host of 

16
00:00:53,270 --> 00:00:56,030
the freely Filtered podcast. 
So Joel, welcome to this 

17
00:00:56,030 --> 00:00:58,630
program. 
Peter, I'm really glad to be 

18
00:00:58,630 --> 00:01:00,750
here. 
I'm a huge kidney go stand. 

19
00:01:01,570 --> 00:01:03,410
Awesome, Awesome. 
Let's get started. 

20
00:01:03,410 --> 00:01:05,690
Let's go back to basic stroll. 
Let's talk about salt. 

21
00:01:05,690 --> 00:01:08,450
What's the latest in the sodium 
story and what's the latest 

22
00:01:08,450 --> 00:01:10,770
thinking? 
And how do you explain sodium 

23
00:01:10,770 --> 00:01:12,530
intake and diets to your 
patients? 

24
00:01:12,850 --> 00:01:15,890
Yeah, Peter, like everything in 
medicine, what we thought was 

25
00:01:15,890 --> 00:01:19,210
simple, the more we looked into 
it became more complex. 

26
00:01:19,410 --> 00:01:23,730
So sodium has been like the 
common villain in nephrology for

27
00:01:23,730 --> 00:01:28,930
fifty, 60-70 years and with the 
advice has always been reduce 

28
00:01:28,930 --> 00:01:30,850
your sodium intake, reduce your 
sodium intake. 

29
00:01:31,400 --> 00:01:35,400
And as we've looked into it more
and more, it's more complex than

30
00:01:35,400 --> 00:01:37,720
that. 
And it does seem that the ratio 

31
00:01:37,720 --> 00:01:41,000
of sodium to potassium intake is
what's really important. 

32
00:01:41,360 --> 00:01:44,560
And that in addition to trying 
to lower your sodium, you want 

33
00:01:44,560 --> 00:01:47,960
to increase your potassium 
intake for optimal vascular 

34
00:01:47,960 --> 00:01:49,480
health. 
And we're seeing that vascular 

35
00:01:49,480 --> 00:01:52,880
health pay dividends in terms of
reduced cardiovascular disease. 

36
00:01:53,320 --> 00:01:55,120
And reduce chronic kidney 
disease. 

37
00:01:55,120 --> 00:01:58,840
So getting that ratio and it's 
not just reducing the sodium, 

38
00:01:58,840 --> 00:02:01,720
but making sure patients get a 
rich source of potassium in that

39
00:02:01,720 --> 00:02:03,960
diet. 
And it kind of rings true when 

40
00:02:03,960 --> 00:02:06,880
you kind of think about in your 
mind what's a healthy diet you 

41
00:02:06,880 --> 00:02:09,360
think of fruits and vegetables 
and those are all going to be 

42
00:02:09,360 --> 00:02:11,720
rich in potassium. 
And that's just a real important

43
00:02:11,720 --> 00:02:13,680
part of that. 
This is best demonstrated in the

44
00:02:13,680 --> 00:02:18,320
recently published SASS trial 
that's SSASS. 

45
00:02:18,720 --> 00:02:23,540
This came out of rural China. 
Where they replaced the usual 

46
00:02:23,540 --> 00:02:27,140
high quality sodium chloride 
that patients use in their salt 

47
00:02:27,140 --> 00:02:31,740
shakers with a mixture of sodium
chloride and potassium chloride.

48
00:02:32,100 --> 00:02:35,220
And so villages that were 
randomized to the potassium 

49
00:02:35,220 --> 00:02:39,540
chloride intervention, those 
villagers had modestly reduced 

50
00:02:39,540 --> 00:02:42,060
sodium intake but a pretty 
significant increase in their 

51
00:02:42,060 --> 00:02:44,820
daily potassium intake. 
And then they followed them for 

52
00:02:44,820 --> 00:02:47,860
a few years and they saw 
reductions in stroke and 

53
00:02:47,860 --> 00:02:52,130
cardiovascular disease and so. 
Pretty nice demonstration that 

54
00:02:52,130 --> 00:02:55,170
it's not just the sodium that 
it's the sodium plus the 

55
00:02:55,170 --> 00:02:57,490
decrease in sodium and increase 
in potassium intake. 

56
00:02:57,810 --> 00:03:00,250
And this is something that I 
find that I'm going to talk to 

57
00:03:00,250 --> 00:03:03,410
my patients, they're all hungry 
for nutritional information. 

58
00:03:03,770 --> 00:03:06,610
A lot of my patients really want
to know, hey, what kind of 

59
00:03:06,810 --> 00:03:09,610
lifestyle modifications, what 
can I do besides just taking 

60
00:03:09,610 --> 00:03:13,850
this pill can I do to minimize 
my risk of being on dialysis? 

61
00:03:13,970 --> 00:03:16,370
And I think this is good advice 
and something that people can 

62
00:03:16,370 --> 00:03:18,790
really operationalize. 
And that makes a lot of sense. 

63
00:03:18,790 --> 00:03:21,390
It's a balancing act that's 
important as opposed to 1 

64
00:03:21,390 --> 00:03:24,430
component or the other. 
So the ratio is important and 

65
00:03:24,510 --> 00:03:25,870
that's something that we didn't 
know about. 

66
00:03:25,870 --> 00:03:28,310
So thanks for bringing that up. 
The other thing is that when 

67
00:03:28,310 --> 00:03:32,910
patients reach out for just kind
of dietary guidelines just using

68
00:03:32,910 --> 00:03:35,790
general Internet, what they 
often see is reduce the 

69
00:03:35,790 --> 00:03:38,790
potassium intake which is you 
know good advice if you're in 

70
00:03:38,790 --> 00:03:42,430
very late stage CKD getting 
close to dialysis where 

71
00:03:42,430 --> 00:03:45,430
potassium becomes a real issue. 
But the for the vast majority of

72
00:03:45,430 --> 00:03:47,910
our CKD patients. 
You know, potassium balance is 

73
00:03:47,910 --> 00:03:51,150
just not an issue for them and 
that, you know, having them 

74
00:03:51,150 --> 00:03:53,590
restrict potassium there is 
probably pushing them towards a 

75
00:03:53,590 --> 00:03:54,670
diet that's not so good for 
them. 

76
00:03:55,230 --> 00:03:57,230
That makes sense because we 
always thought about reducing 

77
00:03:57,230 --> 00:03:59,910
potassium, reducing sodium, 
reducing all of these things. 

78
00:03:59,910 --> 00:04:02,670
But what you're saying is that 
in the early stages that 

79
00:04:02,670 --> 00:04:05,310
balancing acts between sodium 
and potassium is really 

80
00:04:05,310 --> 00:04:08,550
important and not just in terms 
of kidneys, but in terms of 

81
00:04:08,550 --> 00:04:10,950
cardiovascular risk as well. 
Absolutely. 

82
00:04:12,510 --> 00:04:14,950
So Joel, there's been a lot of 
excitement in the last five 

83
00:04:14,950 --> 00:04:17,750
years about SGLT 2 inhibitor 
trials and things like that. 

84
00:04:17,750 --> 00:04:20,510
I've never seen nephrologists so
happy in my life. 

85
00:04:20,709 --> 00:04:23,590
And are we using enough of this 
SGLT 2? 

86
00:04:23,590 --> 00:04:26,910
And specifically, which patients
are you putting on SGLT 2 

87
00:04:26,910 --> 00:04:30,430
inhibitors? 
Well, Peter, I love the Frozens.

88
00:04:30,470 --> 00:04:33,990
And so we need to get away from 
this SGLT 2 inhibitors. 

89
00:04:33,990 --> 00:04:35,430
They're our friends. 
Let's call them by their name, 

90
00:04:35,430 --> 00:04:38,590
there are Frozens. 
So I'm a flozenator, right? 

91
00:04:38,590 --> 00:04:41,030
Every day I get up and I look in
the mirror and I said, who am I 

92
00:04:41,030 --> 00:04:44,540
going to flozenate today? 
And I've been very aggressive 

93
00:04:44,540 --> 00:04:47,700
about getting my patients on 
flosins and I'm finding it 

94
00:04:47,700 --> 00:04:50,100
harder and harder to find new 
patients because the majority of

95
00:04:50,100 --> 00:04:52,340
my CKD patients now are on 
Flosins. 

96
00:04:52,620 --> 00:04:55,620
Last November, we had the 
announcement and simultaneous 

97
00:04:55,620 --> 00:05:00,620
publication of empa kidney, 
which was an important piece of 

98
00:05:00,620 --> 00:05:02,820
evidence in the chain of 
evidence that we have for 

99
00:05:02,980 --> 00:05:06,980
flosins in CKD. 
What empa kidney brought to the 

100
00:05:06,980 --> 00:05:11,660
table was it lowered the GFR 
from the previous. 

101
00:05:12,040 --> 00:05:15,840
Record of 25 milliliters per 
minute down to 20 milliliters 

102
00:05:15,840 --> 00:05:17,800
per minute. 
And so that was kind of a new 

103
00:05:17,800 --> 00:05:21,400
record for how low the GFR can 
go, but we see benefit in these 

104
00:05:21,400 --> 00:05:23,160
patients. 
The other thing that it did is 

105
00:05:23,160 --> 00:05:27,000
it randomized patients both 
without diabetes and without 

106
00:05:27,000 --> 00:05:30,760
proteinuria. 
A lot of the earlier CKD data 

107
00:05:30,960 --> 00:05:35,240
had only enrolled patients with 
proteinuria was one of the 

108
00:05:35,240 --> 00:05:38,640
enrollment criteria, but empa 
kidney did have a tranche of 

109
00:05:38,640 --> 00:05:41,240
patients that had no proteinuria
and. 

110
00:05:41,750 --> 00:05:46,350
Though if you just look in that 
group in isolation, they didn't 

111
00:05:46,630 --> 00:05:50,470
reach the primary endpoint. 
If you look at the slope of GFR,

112
00:05:50,510 --> 00:05:52,510
which is going to be less 
sensitive to events, right, 

113
00:05:52,510 --> 00:05:55,430
because the primary endpoint was
a doubling of serum creatinine, 

114
00:05:55,430 --> 00:05:58,870
initiation of dialysis and those
patients have a very slow 

115
00:05:58,870 --> 00:06:00,150
progression, right? 
They don't have proteinuria, 

116
00:06:00,150 --> 00:06:02,270
They don't have one of the major
risk factors for progression of 

117
00:06:02,270 --> 00:06:04,510
CKD. 
But if you look at the slope of 

118
00:06:04,510 --> 00:06:07,510
GFR, they did have a beneficial 
effect on slope and that really 

119
00:06:07,510 --> 00:06:10,630
reassured me that this is really
a drug for all my patients. 

120
00:06:11,010 --> 00:06:13,410
And then honestly, Peter, if 
you're skeptical about that 

121
00:06:13,410 --> 00:06:16,050
slope because it wasn't the 
primary outcome, you could just 

122
00:06:16,050 --> 00:06:17,610
take a look at the 
cardiovascular data. 

123
00:06:17,610 --> 00:06:20,210
The cardiovascular data enrolled
lots of patients without 

124
00:06:20,210 --> 00:06:24,330
proteinuria and they also had 
lots of cardiovascular benefits.

125
00:06:24,330 --> 00:06:26,970
And I think that's a kind of a 
belt and suspenders approach to 

126
00:06:26,970 --> 00:06:30,290
this drug is that you know, it 
clearly is good for the kidneys,

127
00:06:30,650 --> 00:06:35,390
but the vast majority of. 
Patients with even with advanced

128
00:06:35,390 --> 00:06:38,390
CKD will die of cardiovascular 
disease before they get to 

129
00:06:38,390 --> 00:06:41,270
dialysis and that that's no in 
no way is that a win. 

130
00:06:41,710 --> 00:06:44,790
But having a drug that prevents 
heart failure and prevents 

131
00:06:44,790 --> 00:06:46,710
admissions from heart failure 
and prevents death, the 

132
00:06:46,710 --> 00:06:49,910
cardiovascular death, that's 
also indicating CKD is perfect 

133
00:06:49,910 --> 00:06:51,030
and that's what we have with the
flows. 

134
00:06:51,270 --> 00:06:54,110
Either way you look or any way 
you justify it to the patients 

135
00:06:54,110 --> 00:06:56,590
whether you if they have 
particular fears about dialysis 

136
00:06:56,590 --> 00:06:59,390
you're like this is great for 
dialysis or they have a sketchy 

137
00:06:59,390 --> 00:07:01,830
heart history, you're like well 
this is one of the most powerful

138
00:07:01,830 --> 00:07:03,310
heart medications we've ever 
had. 

139
00:07:03,700 --> 00:07:05,220
Really. 
And the only medicine we've had 

140
00:07:05,220 --> 00:07:07,380
that's been able to help 
patients with heart failure with

141
00:07:07,420 --> 00:07:09,980
preserved ejection fraction. 
So these are you know, 

142
00:07:09,980 --> 00:07:13,260
breakthrough medications and I 
am using them every which way, 

143
00:07:13,260 --> 00:07:15,980
but left, you know, in addition 
to lack of proneuria and lack of

144
00:07:15,980 --> 00:07:19,460
GFR, they have a role in 
patients that have borderline 

145
00:07:19,460 --> 00:07:21,460
hyperkalemia. 
They reduce episodes of 

146
00:07:21,460 --> 00:07:24,060
hyperkalemia. 
Their data came out meta 

147
00:07:24,060 --> 00:07:28,580
analysis of Closings showed that
they reduced episodes of acute 

148
00:07:28,580 --> 00:07:30,460
kidney injury. 
They really are breakthrough 

149
00:07:30,460 --> 00:07:32,500
medications and I'm trying to 
get as many patients on them as 

150
00:07:32,500 --> 00:07:34,380
possible. 
That makes a lot of sense and 

151
00:07:34,380 --> 00:07:36,380
all the studies are pointing in 
that direction. 

152
00:07:36,380 --> 00:07:38,780
And initially we didn't think 
that these were great drugs, 

153
00:07:38,780 --> 00:07:40,380
right? 
But now they're showing up 

154
00:07:40,380 --> 00:07:41,780
everywhere. 
So as you said, in 

155
00:07:41,780 --> 00:07:44,100
cardiovascular patients, they 
were also good for kidney 

156
00:07:44,100 --> 00:07:46,140
disease and heart failure 
patients, good for heart 

157
00:07:46,140 --> 00:07:47,460
failure, good for kidney 
disease. 

158
00:07:47,740 --> 00:07:50,780
And we're now branching out from
diabetes to non diabetes 

159
00:07:50,780 --> 00:07:52,540
patients and having those same 
benefits. 

160
00:07:52,540 --> 00:07:55,180
So you're absolutely right. 
It seems like the population 

161
00:07:55,660 --> 00:07:57,860
that would benefit from this is 
actually quite large now. 

162
00:07:58,520 --> 00:07:59,960
Yeah. 
And we didn't even touch on the 

163
00:07:59,960 --> 00:08:01,360
glomerulone nephritis 
population. 

164
00:08:01,360 --> 00:08:04,920
This is another group, you know,
clearly shown in IGA to have a 

165
00:08:04,920 --> 00:08:08,320
real powerful renal protective 
effect in the IGA population. 

166
00:08:08,680 --> 00:08:10,760
And I think we're going to see 
additional data coming down the 

167
00:08:10,760 --> 00:08:14,840
pipe, little bits, memberness, 
FSGS, you know, that is not 

168
00:08:14,840 --> 00:08:16,240
there yet. 
Those are harder groups to 

169
00:08:16,240 --> 00:08:18,600
gather. 
But my sense is we're going to 

170
00:08:18,600 --> 00:08:21,480
just see this kind of knock off 
one population after another. 

171
00:08:21,930 --> 00:08:23,450
That's great. 
So therefore more and more 

172
00:08:23,450 --> 00:08:25,730
patients will come into the 
funnel where they're going to be

173
00:08:25,730 --> 00:08:28,970
using this as opposed to these 
drugs are for these specific 

174
00:08:28,970 --> 00:08:31,930
patients that net is actually 
getting very, very large now. 

175
00:08:32,250 --> 00:08:35,850
Yeah, it's just a generic kidney
health medicine is it might be a

176
00:08:35,850 --> 00:08:37,370
reasonable way to think about 
it. 

177
00:08:37,530 --> 00:08:40,169
And drugs is incredibly well 
tolerated. 

178
00:08:40,169 --> 00:08:43,570
You know, part of me thinks, oh,
a drug that's that good probably

179
00:08:43,570 --> 00:08:46,610
has a lot of nasty side effects 
and part of the reason that 

180
00:08:46,610 --> 00:08:49,450
people are such fans of the drug
is that it really does. 

181
00:08:49,450 --> 00:08:52,160
It's a pretty clean. 
Profile, the drug is well 

182
00:08:52,160 --> 00:08:53,840
tolerant. 
You know probably the most 

183
00:08:53,960 --> 00:08:57,040
ringing endorsement is that in 
the placebo-controlled trials 

184
00:08:57,280 --> 00:09:00,320
there was no difference in 
patients discontinuing the drug 

185
00:09:00,680 --> 00:09:03,280
from the placebo, which is kind 
of unheard of always. 

186
00:09:03,680 --> 00:09:06,240
You know patients on the active 
group have more discontinuation,

187
00:09:06,240 --> 00:09:08,440
more side effects. 
We're just not seeing that, it's

188
00:09:08,440 --> 00:09:10,120
amazing. 
For those tuning in, you're 

189
00:09:10,120 --> 00:09:13,320
listening to KD Co podcast on 
CKD Interventions. 

190
00:09:13,440 --> 00:09:16,080
I'm Dr. Peter Lynn and I'm 
speaking with Dr. Joel Toff. 

191
00:09:16,410 --> 00:09:19,250
So, OK, Joel, besides SGLT 2 
inhibitors and I think grass 

192
00:09:19,250 --> 00:09:22,290
inhibitors, what are other new 
treatments or interventions that

193
00:09:22,290 --> 00:09:23,610
you're using on your patients 
now? 

194
00:09:24,050 --> 00:09:25,490
Yeah. 
The thing that I'm finding 

195
00:09:25,490 --> 00:09:29,010
that's changing my practice is 
we now have a few different 

196
00:09:29,010 --> 00:09:34,650
choices for patient tolerable 
and effective potassium binders,

197
00:09:35,050 --> 00:09:37,010
right? 
You know, for much of my career,

198
00:09:37,170 --> 00:09:40,090
when we said potassium binders, 
the only story there was 

199
00:09:40,090 --> 00:09:43,370
kaaxalate, which was a 
medication that patients hated, 

200
00:09:43,730 --> 00:09:46,750
couldn't tolerate. 
Didn't taste good, caused 

201
00:09:46,790 --> 00:09:51,430
diarrhea, caused Constipation 
and the idea of using it 

202
00:09:51,430 --> 00:09:53,670
chronically so that you could 
maintain an ace. 

203
00:09:53,670 --> 00:09:56,510
And I I would never entertain it
cuz it was such a miserable drug

204
00:09:56,510 --> 00:09:59,350
to be on. 
But with the ptero mere and 

205
00:09:59,350 --> 00:10:03,070
sodium zirconium cyclosilicate, 
these drugs are well tolerated. 

206
00:10:03,070 --> 00:10:05,670
Patients take them, they don't 
have any trouble with it. 

207
00:10:05,670 --> 00:10:09,350
And I am finding myself reaching
for those more and more in 

208
00:10:09,350 --> 00:10:11,630
select situations. 
You know, patients that. 

209
00:10:11,940 --> 00:10:14,260
To really feel strongly that we 
need to keep them on an ACE 

210
00:10:14,260 --> 00:10:16,500
inhibitor, you know patients 
with advanced heart failure, 

211
00:10:16,940 --> 00:10:19,540
patients with significant 
proteinuria, you know Ras 

212
00:10:19,540 --> 00:10:22,300
inhibition in those situations 
is literally lifesaving. 

213
00:10:22,820 --> 00:10:25,300
And if I need to give the 
patient a potassium binder that 

214
00:10:25,300 --> 00:10:27,500
they take, you know most of the 
patients don't even need to take

215
00:10:27,500 --> 00:10:30,100
a daily or three days a week is 
usually enough to keep their 

216
00:10:30,100 --> 00:10:32,560
potassium safe. 
That's huge, right. 

217
00:10:32,560 --> 00:10:34,480
And I think that's going to make
a huge difference for these 

218
00:10:34,480 --> 00:10:36,880
patients and that you know in 
addition that you know the new 

219
00:10:36,880 --> 00:10:39,520
kid on the block Finerano, you 
know this is a drug that has 

220
00:10:39,520 --> 00:10:42,560
significant hyperkalemia, right.
They didn't even enroll patient 

221
00:10:42,560 --> 00:10:46,520
potassium is more than 4.7. 
And so patients you know solidly

222
00:10:46,520 --> 00:10:49,560
in the normal range of potassium
weren't enrolled in the pivotal 

223
00:10:49,560 --> 00:10:52,600
trials, Figaro and Fidelio. 
If their potassium was at the 

224
00:10:52,680 --> 00:10:55,320
upper limit of normal, well, you
know, here's a way that you 

225
00:10:55,320 --> 00:10:57,840
might be able to get your 
patients to either start the 

226
00:10:57,840 --> 00:11:00,770
drug or stay on it. 
If the potassium drifts up and I

227
00:11:00,770 --> 00:11:02,250
think that's also going to pay 
benefits. 

228
00:11:02,250 --> 00:11:05,690
So I think it's a pretty 
important advancement having a 

229
00:11:05,730 --> 00:11:08,170
tolerable potassium binder 
that's available for patients. 

230
00:11:08,650 --> 00:11:11,130
Yeah, that makes a whole lot of 
sense because if you can offer a

231
00:11:11,130 --> 00:11:13,770
tolerable potassium binder, it 
allows you to keep all your 

232
00:11:13,770 --> 00:11:15,010
other drugs. 
You know, as you were saying, 

233
00:11:15,010 --> 00:11:18,090
the Ras blockers, etc, which is 
one of the things that we used 

234
00:11:18,090 --> 00:11:20,890
to be very afraid of, but now 
you have an option around that. 

235
00:11:20,890 --> 00:11:23,470
So that's actually very good. 
Now when I was in medical 

236
00:11:23,470 --> 00:11:26,990
school, Joe, last century, I 
guess it was basically CKD 

237
00:11:26,990 --> 00:11:29,630
seemed like a very gloomy, doomy
kind of space. 

238
00:11:29,950 --> 00:11:34,270
How do you see CKD now as we're 
moving forward in 2023 and 

239
00:11:34,270 --> 00:11:36,350
forward? 
Peter, you just got to remember 

240
00:11:36,350 --> 00:11:39,470
how new this field was if you 
were in medical school in the 

241
00:11:39,470 --> 00:11:41,660
last century. 
We didn't even call it C Kitty, 

242
00:11:41,660 --> 00:11:43,500
it was chronic renal 
insufficiency. 

243
00:11:43,500 --> 00:11:46,580
We know really like you know 
that was the big advancement 

244
00:11:46,580 --> 00:11:50,780
around what 2000 or 2001 was. 
Let's establish this field of 

245
00:11:50,780 --> 00:11:53,820
chronic kidney disease. 
Let's understand that if we're 

246
00:11:53,820 --> 00:11:56,260
going to help patients that are 
headed towards dialysis or to 

247
00:11:56,260 --> 00:11:59,500
have chronic kidney disease, we 
need to have a language to talk 

248
00:11:59,500 --> 00:12:02,220
about it staging to grade these 
patients. 

249
00:12:02,540 --> 00:12:05,420
And so you know you go back 25 
years, we're really starting 

250
00:12:05,420 --> 00:12:07,220
from the very first steps. 
Hey, let's. 

251
00:12:07,870 --> 00:12:09,710
Figure out the names to call 
this and. 

252
00:12:09,710 --> 00:12:12,350
But you're right since then, you
know, at that time we had ACE 

253
00:12:12,350 --> 00:12:14,430
inhibitors, Arb's were still on 
patent. 

254
00:12:14,430 --> 00:12:16,990
We were talking about them as 
being the expensive medication. 

255
00:12:17,390 --> 00:12:20,710
And now you look around and we 
have just an embarrassment 

256
00:12:20,750 --> 00:12:25,790
riches, an incredible new number
of tools that are available to 

257
00:12:25,790 --> 00:12:29,510
us with a robust evidence base 
where we can really know, hey 

258
00:12:29,510 --> 00:12:32,150
this stuff really works and it 
really works across these 

259
00:12:32,150 --> 00:12:34,910
populations. 
Really, really is amazing, but 

260
00:12:34,910 --> 00:12:37,790
it's not only and CKD, the 
nephrologists are happy because 

261
00:12:37,790 --> 00:12:40,590
we're having new tools to treat 
glomerulonephritis, right. 

262
00:12:40,590 --> 00:12:44,190
We're getting new tools to 
modify the complement cascade, 

263
00:12:44,190 --> 00:12:46,470
probably something we didn't 
even understand when you were in

264
00:12:46,470 --> 00:12:49,790
medical school in terms of its 
importance for 

265
00:12:49,950 --> 00:12:51,510
glomerulonephritis and renal 
damage. 

266
00:12:51,510 --> 00:12:53,790
And now we're getting multiple, 
you already have some tools 

267
00:12:53,790 --> 00:12:55,790
available and additional drugs 
that are on the way. 

268
00:12:55,790 --> 00:12:57,630
I think that those are going to 
be revolutionary. 

269
00:12:58,150 --> 00:13:02,270
We're having new medications 
that are designed solely for. 

270
00:13:02,840 --> 00:13:05,400
Dealing with the symptoms of 
uremia, I'm thinking of that 

271
00:13:05,440 --> 00:13:08,080
like a phalan for itch. 
You know these patients that 

272
00:13:08,080 --> 00:13:11,120
have had CKD associated puritis,
you know we give them some 

273
00:13:11,120 --> 00:13:13,800
Benadryl and and cross our 
fingers knowing that it really 

274
00:13:13,800 --> 00:13:16,000
didn't work. 
And now we have a specific 

275
00:13:16,000 --> 00:13:18,480
medication for this therapy 
that's fairly effective. 

276
00:13:18,520 --> 00:13:21,680
It's amazing the opportunities 
that are out there. 

277
00:13:21,920 --> 00:13:25,120
And then you know we have a new 
endothelial antagonists which 

278
00:13:25,120 --> 00:13:28,240
are you know the first one now 
approved for IGA nephropathy and

279
00:13:28,240 --> 00:13:31,240
I think that's going to be a 
drug that will find additional 

280
00:13:31,240 --> 00:13:33,530
uses and other GN's. 
It's really important. 

281
00:13:33,570 --> 00:13:35,770
And the other thing is on the 
side of diagnosis. 

282
00:13:35,850 --> 00:13:39,370
You know, in the past we were 
limited to kidney biopsies and 

283
00:13:39,370 --> 00:13:42,610
now we have genetic tests that 
are becoming much more 

284
00:13:42,610 --> 00:13:46,170
affordable and opening up much 
more precision in the way of 

285
00:13:46,170 --> 00:13:48,610
diagnosis. 
So it really is an amazing time 

286
00:13:48,610 --> 00:13:50,970
to be a nephrologist. 
And I guess I'm not the only one

287
00:13:50,970 --> 00:13:53,010
who's really happy about it. 
I'm glad that you're seeing 

288
00:13:53,010 --> 00:13:55,730
that. 
And all these tools, whether 

289
00:13:55,730 --> 00:13:57,970
they're diagnostic or 
therapeutics, we need to know 

290
00:13:57,970 --> 00:14:00,770
how to use them and it's almost 
impossible to keep up. 

291
00:14:00,770 --> 00:14:04,330
So I'm glad that. 
PD goes here lighting the way. 

292
00:14:04,330 --> 00:14:07,370
Forward, that's great, Joel. 
So basically, you're telling us 

293
00:14:07,370 --> 00:14:09,970
that there's a lot of positive 
news in this space. 

294
00:14:09,970 --> 00:14:12,250
I think this is a great 
recruitment program for 

295
00:14:12,250 --> 00:14:14,450
nephrologists because 
everybody's excited about this 

296
00:14:14,450 --> 00:14:16,330
field. 
So basically, you're telling us 

297
00:14:16,330 --> 00:14:18,650
that there are a lot of things 
that we can do to help improve 

298
00:14:18,650 --> 00:14:22,170
the lives of our patients with 
CKD ranging from Ras blockade to

299
00:14:22,170 --> 00:14:25,450
SGLT 2 inhibitors, Mra's, 
potassium binders, etcetera, 

300
00:14:25,450 --> 00:14:27,410
etcetera. 
And as you said, riches of 

301
00:14:27,610 --> 00:14:30,420
treatment, which is fantastic. 
And I guess the key is that we 

302
00:14:30,420 --> 00:14:32,420
need to make sure that our 
patients are getting those 

303
00:14:32,420 --> 00:14:34,740
treatments so that they can lead
better lives. 

304
00:14:34,740 --> 00:14:38,060
So thank you Joel, for all your 
Twitter efforts on keeping us up

305
00:14:38,060 --> 00:14:39,900
to date with new CKD 
developments. 

306
00:14:40,180 --> 00:14:42,220
And thank you for taking the 
time today to share your 

307
00:14:42,220 --> 00:14:45,260
insights on CKD interventions. 
Glad. 

308
00:14:45,260 --> 00:14:47,100
To be here, this was excellent. 
Thank you. 

309
00:14:48,420 --> 00:14:49,980
I'm Doctor Peter Lynn signing 
off. 

310
00:14:50,060 --> 00:14:53,020
If you'd like to listen to this 
or other episodes in our series,

311
00:14:53,100 --> 00:14:56,980
please visit kdco.org/podcast. 
Thanks for listening.