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Shared Decision-making in CKD management
Managing CKD: Education and Shared Decision-Making Can Improve Outcomes

Released: November 20, 2023

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Key Takeaways
  • Chronic kidney disease (CKD) affects approximately 1 in 7 Americans, yet patient awareness and education about risk factors and need for early diagnosis is lacking.
  • Patient education is also key to their understanding that CKD now has more available treatment options, including ARBs, ACE inhibitors, SGLT2 inhibitors, and finerenone.  
  • Taking a multidisciplinary approach to CKD management can ensure patients understand their disease and adhere to their treatment.

As a primary care provider (PCP), kidney disease, not surprisingly, is one of the most common chronic illnesses I see in my practice. Further, I see a lot of older adults who are Spanish-speaking and have low socioeconomic status. These patients bear a disproportionate burden of chronic kidney disease (CKD) due to comorbidities like hypertension, obesity, and diabetes. And factors like hypertension and diabetes account for about 75% of all severe CKD cases in the US.

To pull back a little, CKD is incredibly common among US adults. According to data from the CDC, it affects approximately 1 in 7 Americans. Available data are not exact on the overall prevalence of CKD because most adults do not know they have it. Therefore, when we think about diagnosing and managing CKD, educating patients and using shared decision-making strategies are key. 

CKD is a tough disease to start with, seeing as patients who do not realize they have it—including 1 in 3 adults with advanced disease—might experience symptoms and cannot reach a healthcare professional (HCP) because of existing barriers to care. For example, they might not have access to good healthcare, or they could ascribe their fatigue and lightheadedness, among other symptoms, to stress and/or poor sleep. If these individuals do not get properly evaluated, this disease can become a life-threatening issue. 

Starting With Patient Education
Treating CKD starts with patients gaining access to and knowledge from an HCP. It is exciting to see that there are now more public health campaigns promoting CKD awareness nationally and globally. This education is critical because I have seen new patients get upset when I send them for routine lab work, including a comprehensive metabolic panel and urine albumin-creatine ratio (UACR), and soon thereafter tell them that their labs indicate a problem with their kidneys. With the news that their estimated glomerular filtration rate (eGFR) is low and UACR is high, patients can be shocked, dismayed, and highly fearful regarding the risk of renal replacement therapy.

However, most patients I diagnose present at milder stages of CKD, and I reassure them that there are other treatment options available to slow the progression of the disease. My goal, which is something I tell each patient verbally, is to slow their disease progression down: “Although we are not necessarily going to recover kidney function, we are going to slow it down so that it does not promote severe symptoms or even cause significant harm to your overall health." Together, the patient and I can work to prevent the need for renal replacement therapy.

I understand how frustrated patients might be. Many times, I have seen health records be returned several days after I request them, indicating a low eGFR without UACR results. Remember, we need to co-test eGFR and UACR in those at risk of CKD, and particularly in those with hypertension and/or diabetes. I see this happen a lot in my practice, so PCPs should confirm they always include UACR along with eGFR testing. This way, PCPs can better determine patients’ CKD status and educate them on next steps.

Shared Decision-making in Patient–Provider Treatment Discussions
Diagnosing and treating patients with CKD requires good communication, empathy, understanding, and action. We need to empower our patients to know that CKD can be managed effectively. In fact, some of the newer treatment options that we did not have almost a decade ago can really make a difference now. Patients need to understand that there are also things they can do to help their health, starting with lifestyle changes. Eating a healthy diet, maintaining a healthy body weight, and controlling risk factors (eg, hypertension and diabetes) are critical and foundational in the care of patients either at risk for or with established CKD. 

There are currently 3 classes of medications that I prefer to use in patients with CKD. Renin-angiotensin system antagonists, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin-receptor blockers (ARBs) are foundational agents for treating CKD. It is important to ensure patients understand that these medications are used for their benefit in the long term. In addition, because patients are most likely taking other medications, PCPs should make it clear that these agents need to be taken every day. As with other prescriptions, PCPs should walk through the potential side effects and any patient concerns so they feel more comfortable and buy into it as a treatment. In my practice, I want patients to own the fact that they are going to continue taking these medications to help improve their health over time. 

I also recommend the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors—another drug class that has become foundational in the management of CKD. With these prescriptions, PCPs can also discuss some of their other benefits, including improved glycemic control for those with diabetes and some cardiovascular benefits. Finally, I suggest considering the use of finerenone, which is a selective mineralocorticoid receptor antagonist, that is associated with a lower rate of side effects compared with older mineralocorticoid antagonists.

Taking A Multidisciplinary Approach to Care
This is a lot to go over in one visit. In fact, I do not recommend doing this all in one visit, nor do I recommend practicing inertia either. Once a treatment-related decision is made, I often make changes to patients' medication regimen every 4 weeks when needed, while also reinforcing the lifestyle changes to which the patient agreed. What is even better is taking a team-based approach to care if that is available to you. For example, getting a dietician and/or a health coach on board to meet with patients is helpful. 

Lastly, when do we involve nephrology? Well, there is research showing that nephrology feels like they see patients with CKD far too late, and they would like to be engaged earlier in the disease course. Even though the choir is all singing the same song, patients sometimes need to hear it from a different voice like a nephrologist, primary care provider, or health coach. Whoever can really make that contact with patients and emphasize lifestyle changes and treatment adherence, while also getting them to attend their visits and regularly following up for renal function assessment is really important. A patient-centered team is always a great approach to caring for chronic illnesses, including CKD.

Your Thoughts?
In your clinical practice, do you use ARBs, ACE inhibitors, SGLT2 inhibitors, and/or finerenone to treat patients with CKD? Join the conversation by answering the polling question and posting a comment below.

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In your clinical practice, do you use ARBs, ACE inhibitors, SGLT2 inhibitors, and/or finerenone to treat patients with CKD?

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