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Clinical Grade: Episode 1 - Transforming Kidney Care with Dr. Joseph Vassalotti, NKF Plus: Tamara Walker, kidney health advocate and transplant recipient

Transforming Kidney Care: Podcast with Dr. Joseph Vassalotti of the NKF

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These are exciting times for healthcare. The health challenges facing society have never been more complicated, and never have the solutions been more innovative. We’re proud to present you with Healthy.io’s podcast, Clinical Grade, where every month you’ll have a chance to hear our conversations with some of the world’s leading visionaries at the nexus of health and technology.

We’re launching Clinical Grade with a special episode for National Kidney Month. Our guest is Dr. Joseph Vassalotti, the Chief Medical Officer of the National Kidney Foundation, and a clinical professor at the Icahn School of Medicine at Mount Sinai.

Together with Dr. Jonah Mink, a practicing family doctor and Medical Director here at Healthy.io, we’ll discuss how to align incentives and maximize the strengths of healthcare systems, primary care clinicians, and patients when fighting chronic kidney disease. You’ll also hear about the NKF’s efforts to raise awareness of kidney disease, including the “Are You the 33%?” campaign with Healthy.io. And before we sign off, we’ll introduce you to Tamara Walker, of Athens, Georgia. She’ll share her experiences undergoing kidney dialysis and transplant, and advocating for kidney health.

You can listen to Clinical Grade using the player above, and subscribe on  Apple Podcasts, Spotify, Google Podcasts,  or wherever you get your podcasts. 

Episode Transcript

Part 1 – Dr. Joseph Vassalotti

Dr. Vassalotti, thank you so much for joining us. It’s National Kidney Month, which is probably a very busy and important time for the NKF. Could you tell us what you’ve been up to?

Dr. Joseph Vassalotti Sure, so thank you for covering kidney disease. This is Kidney Month, as you mentioned. NKF has an awareness campaign among Americans, it’s one in three, or “Are You the 33%?” Are you at risk for kidney disease? I think it’s important that people understand that knowing that you’re at risk for kidney disease can help motivate you to better treat your risk conditions. I think what’s important for people to understand, and one of the reasons why awareness is so low, is that most people with kidney disease, especially earlier stages of kidney disease, feel well. They don’t they don’t feel sick, and they don’t know they have it. And really, the only way that they can find out is to partner with their clinicians for the blood and the urine testing. 

Dr. Jonah Mink I think that the focus on patient education and awareness raising, especially because CKD is often asymptomatic, is really fantastic. I think that the other side of that coin is how do we engage the clinician, who is caring for the patients who are at risk for CKD, and how do we help them understand the most up to date clinical algorithms and best practices for screening and treatment of their high-risk patients? I know that as a family doctor, before I really dove into this, I was not so familiar with the best practices in terms of blood and urine testing and risk stratification for my patients. Supporting clinicians, especially primary care clinicians, in that way is very important. I’m interested to hear how you, the NKF, and other leaders in the field are streamlining clinical care pathways and protocols for family doctors to refer to, so that they can stay up to date with the best practices in screening and advances in treatment as well.

Dr. Vassalotti Thank you for raising that. So certainly most of kidney disease care occurs in the primary care setting, and so we applaud you and clinicians like you that care for patients in the primary care setting. I think we need to think about your workflow and how to incorporate kidney disease testing into your workflow. In the United States, the National Kidney Foundation has something called CKDintercept. So we do offer a number of strategies. Something called the kidney profile, which is a test that you can order with one click of the mouse, or for using a written order form, a check of a box, to have both the urine albumin-to-creatinine ratio and the estimated GFR test done to potentially diagnose or risk stratify your patient if they are a risk for kidney disease, or have it, respectively. I think we need to work with primary care clinicians about education for better management of the risk factors, particularly risk factor control, which is often more challenging in patients with decreased kidney function. Controlling the blood pressure is often more challenging. I think the other thing is to give you more time. So how do we give you more time per patient? And if we help improve reimbursement for complicated patients—and kidney disease patients are complicated—there are some hierarchical codes that you can use that will help improve reimbursement, at least in the United States. And we also have a HEDIS measure for testing the kidney profile for people with diabetes, American adults, that includes the estimated GFR on the urine albumin to creatinine ratio test annually. So those, I think, will help give you more time to manage your patient, because I think time is something that a primary care clinician needs, particularly to manage complex patients with kidney disease who often have many comorbidities, which which we mentioned earlier, like diabetes, high blood pressure and cardiovascular disease to start with. 

Dr. Mink I definitely resonate with all of those points. I would add that the access to streamlined risk stratification methodology for patients at risk for CKD really enables the family doctors and other primary care clinicians to leverage the new treatments that are available now as well. It’s an empowering thing to have these new treatment options, like the SGLT2 inhibitors and other newer medications that can address the comorbidities, as well as directly impact the kidney disease itself.

Dr. Vassalotti, earlier in our conversation you briefly mentioned the 33 percent campaign and quiz, which we’re proud supporters of. Could you talk a bit more about the campaign and its goals? 33 percent is a pretty shocking statistic. 

Dr. Vassalotti People with diabetes make up about 32 million Americans. And people with hypertension are more than one hundred million Americans. So right there you have about one in three Americans at risk for kidney disease, and I didn’t touch on the other risk conditions we mentioned. So it’s a very common situation that a person is at risk for kidney disease. To help them understand what their risk conditions are and what what can they do about it, partner with their primary care clinician. And there is a website, MinuteForYourKidneys.org, that they can go to and fill out a very simple quiz, and answer questions, and then be informed about their risk of kidney disease, and a little bit about what to do next, and even about what kinds of questions they might ask their primary care clinician, about further evaluation and testing. So I think it’s an exciting time. This is really about perceived risk. We talked about awareness, that’s if I have the condition already. This is perceived risk. And I think if we improve perceived risk, we can help even prevent kidney disease, potentially. Because patients or people living with diabetes will better manage their condition. But also, even if they go on to develop kidney disease, they will probably be more aware of it to start with and they will be more engaged and they will be better able to participate in some of the lifestyle modification and understanding some of the medications that we talked about today. And I think it’s  exciting that we have some medications for blood pressure—ACE inhibitors and angiotensin receptor blockers. We want primary care clinicians to think of those as kidney protective medicines, not just another blood pressure medicine, but kidney protective. So we want to try to maintain those medicines as much as we can. And the same goes for the SGLT2 inhibitors that Jonah Mink mentioned earlier, that we want to think about those not as diabetes drugs, per se, but as kidney and cardio protective medications that we should try to maintain for our patients to protect the organ. So I think that those two interventions are really exciting, because they offer us new tools in the toolbox. I think we have an interdisciplinary care , we have risk factor control, and we have some medications that are particularly protective of the kidney and the heart that are really exciting. 

Dr. Mink What’s particularly striking to me is that the streamlining and simplification of the risk stratification, supported by the HEDIS metric that you mentioned, and represented in the KDIGO guidelines, really gives a very nice framework for primary care clinicians, and gives an orientation about, “well, at this level of kidney damage, I should be honing in and focusing on these treatment areas and disease modifying activities, but at this other level of kidney disease, I should be focusing elsewhere.” And that orientation, that structure is very beneficial for otherwise extremely busy family doctors, to be able to put the kidney in the right place in their minds, and to help the patient conceptualize the risk and the perceived danger of not treating, and being able to focus clearly on what can be used to treat their particular condition, given its stage within the framework.

Dr. Vassalotti Thank you. I agree, and the other aspect of the 33 percent campaign, or the risk campaign, is that we want to make sure that we drive to health equity. I think in 2020 and 2021, certainly the racism and disparities in medicine, and inequities in health care and medicine in the United States, have really come to the forefront. And so we want to recognize that Blacks or African-Americans, Hispanics or Latinos, Native Americans, Asians, Pacific Islanders and Hawaiian natives all have increased risk of kidney disease. We want to make sure that we reach those populations and do our best to drive to health equity, to improve the social determinants of health that often contribute to chronic kidney disease. And unfortunately, the COVID-19 pandemic has only worsened the health inequities that we experience, at least in the United States. And so I think as a society, we need to do better and we need to drive to health equity. And I think kidney disease is a good example of a condition that has these inequities that have been worsened by COVID-19. So anything we do to improve awareness and improve perceived risk, with the risk campaign, should certainly reach those populations. And we want to we want to do more for those populations. 

Thank you very much for that. One last question before we wrap things up.  We know that a great many people at risk just don’t go to the lab to take their routine urine ACR tests. This a challenge that we’re working hard to address here, but I wanted to ask you what you see as some of the best measures for engaging those people who just aren’t getting tested and are missing out on early detection.

Dr. Vassalotti Well, I think flexibility in testing is desirable. So allowing patients to go to a laboratory near their home is one option. Some laboratories will have phlebotomists come to the patient’s home to do the laboratory tests or collect the urine. And there are other ways that home-based testing can be performed that I think are attractive. And I think that when we have multiple options, in addition to the standardized iconic clinician visit with a blood draw and a urine specimen collection, I think that flexibility in testing will help patients achieve more testing. And I didn’t mention that for the albuminuria test for people with diabetes in the United States, only about 30 to 50 percent of Americans adults with diabetes receive that test in a year. We think that percentage should be much higher, close to a hundred percent. And if we look at hypertension in the United States, it’s about five to 10 percent of Americans get that urine albumin-to-creatinine ratio test annually. So we certainly want to do everything we can to improve albuminuria testing. The eGFR test is much more routinely done because it’s part of typical panels that clinicians order routinely. And the urine albumin to creatinine ratio test is special because it’s specifically for kidney disease and it means the clinician’s really thinking about kidney disease. 

Dr. Vassalotti, thank you very much for joining us.

Part 2 – Tamara Walker

And now for something special. After our deep dive into kidney health from a clinical perspective, we’re going to hear the story of a patient. Tens of millions of Americans suffer from kidney disease. Tamara Walker, from Athens, Georgia, was one of them, before she became a passionate advocate for kidney health. We spoke a few days ago. This is her story.

Tamara Walker: I’m Tamara Y. Walker, and I live in the United States, in Georgia, as a matter of fact. I’m a mother of two young adult sons. They’re in their early 20s. I also am a caretaker of my elderly mother who has dementia. And as you know, I’m an advocate and an ambassador that speaks out against kidney disease and also for kidney awareness in my community and to elected officials. 

When she was 25, Tamara discovered she had something called polycystic kidney disease, a hereditary form of kidney disease.

I have autosomal dominant polycystic kidney disease. That is hereditary, but I did not think it would happen to me. You know how when you’re young you think you’re invincible? I just never thought that would happen to me, especially at an early age. I was in my mid-20s, I had just got married, I had my second son, so life was good for me. And then there’s this blow, hey, you’ve got polycystic kidney disease. And that was a whammy. But you press forward, you press through, you can still live, even though you have this illness.

Tamara returned for tests and checkups, but her health deteriorated. Her situation was further complicated by on-again-off-again health insurance. She was told that she would eventually need transplant or dialysis, and she applied for a spot on the transplant list. Her kidney function continued to fall, and there was no donor in sight.

So when I went into dialysis I was fearful but grateful. I was kind of looking forward to going to dialysis, so I can get those toxins out of my blood, so that I can feel better. But still kind of fearful. And so I started dialysis successfully. But then there was kidney cancer.

Tamara’s doctors discovered that she had renal cell carcinoma—kidney cancer. She had both of her kidneys removed. And that’s when her story finally took a turn for the better.

Guess what. Seven months later, after both those kidneys were removed, I got the call I was waiting on from the transplant office, the deceased kidney transplant list. It was my turn. I got the call while I was traveling. I said hello. And they asked, is this Tamara? I said, this is she. And I remember the lady kept saying something about the kidney, but I thought it was the doctors. It was a weekend. And I was like, OK, it’s the weekend, I can’t do anything, I’ll have to wait until Monday, is what I told her. And she says, you didn’t hear me. She says, we have a kidney for you, a transplant. You need to make your way to the transplant hospital. I was so excited to hear those words, I was so excited. Like I said, I was driving on my way back home. I had to pull over, because I was so excited, screaming, excited.

I’m just so grateful to be living, and for the support of my family, my faith. My faith helped me get through this ordeal. And I’m just so thankful for the support of my family, the support of all those organizations that helped me when I did not have insurance. The doctor, the nephrologist, that helped me when I didn’t have insurance, because dialysis is very expensive. And so I had to also do some fundraising in order to get this kidney. The community helped me in that. So definitely, it was a great ordeal, but I am so thankful to be here.

Tamara became a grassroots advocate for kidney health.

This is why I advocate, to let everyone know. All right. You don’t have to suffer and stay there. You can reach out to others in your community. For me, the kidney community. There are many different websites online you can go to. The National Kidney Foundation is one of them. 

When Tamara talks with people about kidney health, she highlights the simple steps that can make a difference for millions—and especially for minority groups.

There are over thirty seven million people with kidney disease here, and a lot of them don’t even know it. So we want to get the word out for them to be checked for kidney disease. A simple urine sample can tell them. All of these things that we can do when we’re getting an annual exam. We just want to share awareness. As far as minorities, for me, African-American, there are many cases of diabetes and hypertension in our population. There are many cases, especially here where I live, in the Southern region of the States. Many people eat fast food on a regular basis. We can try to eat healthy, as healthy as possible. And then here’s another disparity that we’re talking about, the economic disparity. So many people eat in that fashion because they don’t have the funds to afford a healthy lifestyle, or healthy eating, or healthy living. So that’s one thing that we want to do as well. And what I do is reach out to our elected officials. So here in Georgia, I’ve reached out with one of our senators already, and I am looking forward to another meeting with the other senator, to speak out about kidney disease. And so, yeah, so we’re doing all of that for Kidney Month, and not just for Kidney Month—every day! Because kidney disease does not take a break.

If you’d like to hear more from Tamara Walker, her book is called Medical Bill from Heaven. Thanks to Tamara, and of course to Dr. Joseph Vassalotti, and Dr. Jonah Mink for joining us today. And thank you all for listening. This has been Clinical Grade by Healthy.io. We’ll see you again next month. If you enjoyed our podcast, please be sure to subscribe and to leave us a 5-star rating. To learn more about what we do, including at home urinalysis for early detection of CKD, you’re welcome to visit our website at Healthy.io. There you can also subscribe to our newsletter. Or reach out to us for more information. Until next time, keep well, stay healthy.

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