1 00:00:01,920 --> 00:00:05,840 Welcome to this episode of KD Go Conversations in Nephrology. 2 00:00:06,240 --> 00:00:11,280 This episode, titled Early Detection of CKD, is provided by 3 00:00:11,280 --> 00:00:15,160 KD Go and is supported by an independent educational grant 4 00:00:15,400 --> 00:00:18,840 from AstraZeneca. Here's your host, Doctor Peter 5 00:00:18,840 --> 00:00:22,240 Lynn. Hello and welcome to KD Co 6 00:00:22,240 --> 00:00:25,400 Conversations in Nephrology. I'm Doctor Peter Lynn, Director 7 00:00:25,400 --> 00:00:27,600 of Primary Care Initiatives at the Canadian Heart Research 8 00:00:27,600 --> 00:00:29,580 Center. And family physician in Toronto, 9 00:00:29,580 --> 00:00:33,020 Canada and joining me to discuss the importance of early CKD 10 00:00:33,020 --> 00:00:35,820 detection is Dr. Shrilika Tomapalli. 11 00:00:36,140 --> 00:00:39,340 Dr. Tomapalli is a nephrologist and health services researcher 12 00:00:39,340 --> 00:00:42,580 at Well Cornell Medicine and her clinical and research interests 13 00:00:42,580 --> 00:00:46,220 include population health and health policy in CKD Doctor 14 00:00:46,220 --> 00:00:47,860 Tomapalli. Welcome to the program. 15 00:00:48,100 --> 00:00:50,300 Thank you for having me. It's really good to have you 16 00:00:50,300 --> 00:00:53,180 here and we've been having these discussions about kidneys and we 17 00:00:53,180 --> 00:00:56,140 know that our kidneys rarely complain until they're very 18 00:00:56,140 --> 00:00:58,260 badly damaged. So therefore we have to go 19 00:00:58,260 --> 00:01:01,260 looking for CKD. So who should we be thinking 20 00:01:01,260 --> 00:01:03,740 about when it comes to screening for CKD? 21 00:01:03,740 --> 00:01:07,100 What particular patient populations should we prioritize 22 00:01:07,100 --> 00:01:10,700 CKD screening? The first group I'll mention is 23 00:01:10,700 --> 00:01:14,420 patients with diabetes. So in many high income countries 24 00:01:14,420 --> 00:01:18,460 diabetes accounts for half the cases of end stage kidney 25 00:01:18,460 --> 00:01:22,860 disease and early stage CKD is really prevalent among this 26 00:01:22,860 --> 00:01:25,140 population. So patients with diabetes. 27 00:01:25,620 --> 00:01:30,660 About 1/3 of them have CKD. And so there's several national 28 00:01:30,660 --> 00:01:34,620 and international guidelines that recommend CKD screening 29 00:01:34,620 --> 00:01:36,980 yearly in patients with diabetes. 30 00:01:37,300 --> 00:01:40,260 And it's important to remember that a lot of these patients, 31 00:01:40,500 --> 00:01:45,340 their GFR is normal, but they have elevated albumin area until 32 00:01:45,340 --> 00:01:48,300 the very end. So you know, it's very important 33 00:01:48,300 --> 00:01:52,340 to do both the blood testing as well as the urine testing, the 34 00:01:52,340 --> 00:01:54,420 urine testing for protein and albumin. 35 00:01:54,760 --> 00:01:58,280 Other populations that I'll mention, there's some consensus 36 00:01:58,280 --> 00:02:02,920 that patients with hypertension should be screened for CKD and 37 00:02:02,920 --> 00:02:05,560 with CKD and hypertension we have this bidirectional 38 00:02:05,560 --> 00:02:09,280 relationship. CHF as well causes cardio renal 39 00:02:09,280 --> 00:02:13,680 syndrome and patients with CHF have a high prevalence of CKD. 40 00:02:14,240 --> 00:02:17,040 As well as patients with atherosclerotic cardiovascular 41 00:02:17,040 --> 00:02:20,120 disease, they have a high problems of CKD, so should be 42 00:02:20,120 --> 00:02:24,040 considered for CKD screening. So Hidigo had a controversies 43 00:02:24,040 --> 00:02:28,480 conference in 2019 that you know we both had the opportunity to 44 00:02:28,480 --> 00:02:32,720 participate in on early detection in CKD and the 45 00:02:32,720 --> 00:02:35,800 conclusion of that conference with is that these three 46 00:02:35,800 --> 00:02:40,760 populations, diabetes, hypertension and cardiovascular 47 00:02:40,760 --> 00:02:43,480 disease should be prioritized for CKD screening. 48 00:02:44,070 --> 00:02:46,230 Yeah, that's actually a very easy list to remember because 49 00:02:46,230 --> 00:02:49,470 that's the bulk of our patients that we see on a daytoday basis. 50 00:02:49,830 --> 00:02:52,430 And as you put it, that we have to measure both the blood as 51 00:02:52,430 --> 00:02:54,070 well as the urine. So the e.g. 52 00:02:54,070 --> 00:02:56,230 F are the speed of the kidney. That's what I always tell my 53 00:02:56,230 --> 00:02:57,830 patients, that's the speed of your kidney. 54 00:02:57,830 --> 00:03:00,270 You know how fast it works. And then the albumin in the 55 00:03:00,270 --> 00:03:02,990 urine would tell us about, you know, the leak in the quality of 56 00:03:02,990 --> 00:03:05,430 the filter. So diabetes, hypertension, 57 00:03:05,430 --> 00:03:07,870 cardiovascular disease, that's a big chunk of our daily 58 00:03:07,870 --> 00:03:11,350 population that we see. Are there any other risk factors 59 00:03:11,350 --> 00:03:14,670 or red flags that we should be looking for that might be tied 60 00:03:14,670 --> 00:03:17,630 to higher risk of CKD as well, in addition to diabetes, 61 00:03:17,630 --> 00:03:19,270 hypertension and cardiovascular disease? 62 00:03:19,510 --> 00:03:21,630 Yeah, there are other risk factors. 63 00:03:21,630 --> 00:03:23,710 One is family history of kidney disease. 64 00:03:23,710 --> 00:03:27,230 So for every patient, you know, we should be asking them if they 65 00:03:27,230 --> 00:03:30,560 have family members on dialysis. And that might be due to 66 00:03:30,560 --> 00:03:33,760 diabetes in the family, but there's other genetic factors as 67 00:03:33,760 --> 00:03:36,520 well, you know, collagen mutations, kind of other genetic 68 00:03:36,520 --> 00:03:38,880 factors that are continually being discovered. 69 00:03:39,080 --> 00:03:42,600 So family history also really comes into play with polycystic 70 00:03:42,600 --> 00:03:45,400 kidney disease, which is autosomal dominant. 71 00:03:45,400 --> 00:03:49,280 Inheritance patients with lupus are also at risk for kidney 72 00:03:49,280 --> 00:03:52,520 disease and there's other conditions that pose a risk for 73 00:03:52,520 --> 00:03:55,640 kidney disease as well. So if they have a history of 74 00:03:55,640 --> 00:03:59,560 severe a Ki, if they were hospitalized obesity. 75 00:04:00,000 --> 00:04:04,680 IV drug use, hepatitis and uncontrolled HIV are all risk 76 00:04:04,680 --> 00:04:08,600 factors as well as any patients that are chronically taking 77 00:04:08,840 --> 00:04:11,040 medications that are nephrotoxic. 78 00:04:11,240 --> 00:04:15,560 So like lithium or NSAIDs. And luckily you don't need to 79 00:04:15,560 --> 00:04:18,920 remember this full list. The International Society of 80 00:04:18,920 --> 00:04:24,480 Nephrology has a Quick guide to CKD early identification so you 81 00:04:24,480 --> 00:04:27,520 can find that online and that lists out all these high risk 82 00:04:27,520 --> 00:04:29,880 conditions. And that sounds a really like a 83 00:04:29,880 --> 00:04:32,400 good list that we should keep. And and I think you mentioned 84 00:04:32,480 --> 00:04:35,280 something there that torked my attention which was and SAIDS, 85 00:04:35,280 --> 00:04:38,360 we have so many patients taking and SAIDS and they might not be 86 00:04:38,560 --> 00:04:40,080 telling us. So that's something that we can 87 00:04:40,080 --> 00:04:42,240 ask for. And I must admit I never thought 88 00:04:42,240 --> 00:04:44,800 about family history, how important that is because I can 89 00:04:44,800 --> 00:04:47,320 give you a guide as to whether there's kidney disease within 90 00:04:47,320 --> 00:04:49,560 the family. So those are all very useful 91 00:04:49,560 --> 00:04:52,000 sort of practical tips for those just tuning in. 92 00:04:52,000 --> 00:04:55,000 You're listening to KD Co podcast on early detection of 93 00:04:55,000 --> 00:04:57,120 CKD. I'm Doctor Peter Lynn and I'm 94 00:04:57,120 --> 00:05:00,960 speaking with Doctor Tomapalli. Now CKD is found everywhere in 95 00:05:00,960 --> 00:05:04,320 the world, but what are the differences between countries? 96 00:05:04,320 --> 00:05:07,960 Are there any country specific factors that might affect how we 97 00:05:07,960 --> 00:05:10,480 screen for CKD? Absolutely. 98 00:05:10,480 --> 00:05:14,720 I think in each country the approach to CKD screening really 99 00:05:14,720 --> 00:05:17,840 needs to be tailored to that individual context. 100 00:05:17,840 --> 00:05:20,920 And a lot of especially low and middle income countries, they 101 00:05:20,920 --> 00:05:24,200 have limited access to CKD diagnostic testing. 102 00:05:24,200 --> 00:05:27,680 So some of the more expensive, you know, blood and urine tests. 103 00:05:28,070 --> 00:05:31,350 Some things to keep in mind, there are certain areas that 104 00:05:31,350 --> 00:05:36,110 have a high burden of what's called Ckdu, so CKD of unknown 105 00:05:36,110 --> 00:05:38,830 origin. It's predominantly found in 106 00:05:38,830 --> 00:05:42,950 agricultural areas, sugar cane farming areas where workers are 107 00:05:42,950 --> 00:05:46,430 at risk for dehydration. So this is increasingly found in 108 00:05:46,430 --> 00:05:49,550 many pockets of the world. So definitely if you're in that 109 00:05:49,550 --> 00:05:51,670 type of area, that's something to keep in mind. 110 00:05:52,190 --> 00:05:54,510 And then IGA nephropathy is another one. 111 00:05:54,510 --> 00:05:57,310 It has higher incidence in Japan for instance. 112 00:05:57,310 --> 00:06:00,910 So they adopt A universal population wide screening 113 00:06:00,910 --> 00:06:02,990 policy. So definitely you know, follow 114 00:06:02,990 --> 00:06:07,230 your country specific guidelines and each country might have an 115 00:06:07,230 --> 00:06:10,550 assessment for what makes sense in that particular region. 116 00:06:11,050 --> 00:06:13,370 Yeah, those are good points. In other words, the testing may 117 00:06:13,370 --> 00:06:15,850 not be available and more importantly there may be 118 00:06:15,850 --> 00:06:18,250 different diseases that are more predominant. 119 00:06:18,250 --> 00:06:20,970 I never thought about the different types of diseases that 120 00:06:20,970 --> 00:06:24,250 may be causing CKD would vary across the world as well. 121 00:06:24,250 --> 00:06:26,530 So that's very important. And so that's why you know the 122 00:06:26,530 --> 00:06:29,170 country specific guidelines are so useful as well. 123 00:06:29,170 --> 00:06:31,730 So all of that is very good and this conversation has. 124 00:06:32,140 --> 00:06:34,540 Given me a lot of thought as to what I should be bringing back 125 00:06:34,540 --> 00:06:37,300 to my practice, are there any other things that you want to 126 00:06:37,300 --> 00:06:40,100 give as a final message to our listeners in terms of early 127 00:06:40,100 --> 00:06:42,820 detection and why we should be, you know, focusing in on that 128 00:06:42,980 --> 00:06:45,340 for our CKD patients? Yeah, I think. 129 00:06:45,830 --> 00:06:49,630 You know early detection of CKD is more important today than 130 00:06:49,630 --> 00:06:54,430 ever before because we have so many exciting therapeutics now 131 00:06:54,430 --> 00:06:59,190 we have new medications to treat CKD and delay disease 132 00:06:59,190 --> 00:07:01,310 progression. So you know, I know you'll talk 133 00:07:01,310 --> 00:07:04,790 about those further in a later podcast, but it's really an 134 00:07:04,790 --> 00:07:06,710 exciting time and having all these. 135 00:07:07,140 --> 00:07:11,500 Chances to intervene early and modify the disease course is 136 00:07:11,500 --> 00:07:14,540 really going to help so many patients across the world who 137 00:07:14,540 --> 00:07:17,860 are living with kidney disease. I guess that's very rewarding 138 00:07:17,860 --> 00:07:20,860 right now for you, right. So whereas before we find people 139 00:07:20,860 --> 00:07:24,580 with CKD and dialysis was the sort of the only option, but now 140 00:07:24,860 --> 00:07:27,020 there are lots of medications and things that we could do 141 00:07:27,020 --> 00:07:29,260 before that, right? That must be very rewarding for 142 00:07:29,260 --> 00:07:31,580 you to see that as well. Oh, absolutely. 143 00:07:31,580 --> 00:07:34,420 I think seeing as a nephrologist seeing patients in clinic. 144 00:07:34,860 --> 00:07:37,580 Before, when they would ask you what can I do about my kidney 145 00:07:37,580 --> 00:07:40,660 disease Now we have so many options for them, lifestyle 146 00:07:40,660 --> 00:07:44,780 interventions, medications, you know, not just Ras inhibitors, 147 00:07:44,780 --> 00:07:47,740 but SGLT Two's, Minerallocorticoid receptor 148 00:07:47,740 --> 00:07:50,180 antagonists, GLP one receptor antagonists. 149 00:07:50,180 --> 00:07:51,900 The field is very bright right now. 150 00:07:52,390 --> 00:07:54,470 That's great. That list is a very hopeful list 151 00:07:54,470 --> 00:07:56,950 and that's a great way to round out our discussion today. 152 00:07:56,990 --> 00:07:59,230 So we know that our kidneys are hard workers. 153 00:07:59,230 --> 00:08:01,670 They never complained. So therefore we have to go check 154 00:08:01,670 --> 00:08:03,630 in on them. So that's why early screening 155 00:08:03,630 --> 00:08:05,990 might be a good idea. And you gave us a nice short 156 00:08:05,990 --> 00:08:08,590 list that we can handle. You know, our diabetes patients, 157 00:08:08,590 --> 00:08:11,070 hypertensive patients, cardiovascular disease, 158 00:08:11,070 --> 00:08:14,030 astroscritic cardiovascular disease patients are all people 159 00:08:14,030 --> 00:08:16,190 that we see regularly. So therefore we should screen 160 00:08:16,190 --> 00:08:17,950 them. And you gave us some very good 161 00:08:17,950 --> 00:08:20,670 useful information about family history and the other types of 162 00:08:20,670 --> 00:08:22,310 kidney diseases that we could detect. 163 00:08:22,390 --> 00:08:25,950 Systemic diseases like lupus and these are all things that may be 164 00:08:25,950 --> 00:08:28,950 rare, but if we can find them, as you pointed out, there's so 165 00:08:28,950 --> 00:08:32,190 many things that we could do for those patients once we identify 166 00:08:32,190 --> 00:08:33,789 them. So let's make sure that we 167 00:08:33,789 --> 00:08:37,470 identify them early so that way we can intervene and change the 168 00:08:37,470 --> 00:08:40,669 course of our patients future. I want to thank you, Dr. 169 00:08:40,669 --> 00:08:43,630 Tomapalli, for joining me today and sharing your great insights 170 00:08:43,909 --> 00:08:46,550 and the importance of early detection of CKD. 171 00:08:46,630 --> 00:08:48,790 Thank you very much. Thank you for having me. 172 00:08:50,150 --> 00:08:52,910 I'm Dr. Peter Lynn, signing off. If you'd like to listen to this 173 00:08:52,910 --> 00:08:57,630 or other episodes in our series, please visit kdeco.org/podcasts. 174 00:08:57,830 --> 00:08:58,590 Thanks for listening.