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Find a compact sampling of 2022 chronic kidney disease research reviewed on Patient Care, chosen by the editorial staff.  

Chronic Kidney Disease: Top Papers in 2022

Peer mentor programs can provide support for patients, especially when it comes to family planning and parenthood.

The Importance of Connecting Patients with ADPKD with Each Other

Empagliflozin achieved a decrease in risk of kidney disease progression of 28% vs placebo in the most diverse population of patients in an SGLT-2 inhibitor trial. 

Empagliflozin Reduced Risk of Renal Disease Progression, CV Death Across CKD Spectrum in EMPA-KIDNEY

The findings underscore the importance of routine eGFR and UACR screening in primary care to ensure early detection of CKD and avoid related adverse outcomes. 

Finerenone Mitigates HF, CV Risk Across Baseline Renal Function in Patients with T2D 

CMHC. PCPs and cardiologists appeared to perform only half of items considered necessary for care of T2D patients in a new simulated patient study. 


PCPs, Cardiologists May Not Adequately Stratify, Treat CV Risk in Patients with Type 2 Diabetes 

Patient Care spoke with renowned cardiologist Dr Mikhail Kosiborod and widely-recognized family physician Dr Neil Skolnik, about the expanded indications for sodium-glucose cotransporter-2 (SGLT2) inhibitors and how their availbility creates the perfect opportunity to broaden the scope of type 2 diabetes (T2D) management, with treatment goals that target a patient's full cardiometabolic profile, not elevated blood glucose alone.  

In this final part of the conversation Kosiborod and Skolnik each highlight 3 thoughts for primary care clinicians to keep in mind that will help broaden their view of caring for their patients with T2D.  

For more of the conversation with Drs Kosiborod and Skolnik, please see:  

SGLT-2 Inhibitors Belong to Patients, Not a Specialty or Primary Care: Experts Discuss

Where Should SGLT-2 Inhibitor Therapy Begin? Thoughts from Drs Mikhail Kosiborod and Neil Skolnik

is professor of medicine, University of Missouri Kansas City, vice president, Research, Saint Luke’s Health System, executive director, Cardiometabolic Center Alliance, Director, Cardiometabolic Research and codirector, Haverty Cardiometabolic Center of Excellence, Saint Luke’s Mid America Heart Institute, Kansas City, MO.

is professor of family and community medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

Videos

Drs Mikhail Kosiborod and Neil Skolnik discuss this unique moment in the history of T2D management that offers treatments to address its broad cardiometabolic impact. 

Diabetes

Cardiovascular Disease

Beyond HbA1c: Take a Global Approach to Type 2 Diabetes Management, Use all the Tools 

Hiddo Heerspink, PhD, PharmD, was emphatic that general pracitioners can significantly improve the renal health of their patients with type 2 diabetes by following guideline recommendations to measure eGFR and UAC annually. 

Here he talks with Patient Care about preliminary findings on the potential role for the novel dual incretin agent tirzepatide in slowing the progression of renal disease, or even stopping it and preventing advanced disease and dialysis.  

, is professor of clincal trials and personalized medicine and a clinical pharmacologist/trialist in the department of clinical pharmacy and pharmacology at the University Medical Center Groningen in Groningen, Netherlands; he is also Codirector of the Better Treatments Program at the George Institute for Global Health in Newtown, Australia.

ADA 2022: Professor Hiddo Heerspink led the prespecified SURPASS-4 analysis that found tirzepatide associated with a 41% reduction in risk of a composite renal outcome. 

Kidney Outcomes with Tirzepatide in T2D: Hiddo Heerspink, PhD, PharmD Highlights SURPASS-4 Analysis  

Following is the second of a 3-part discussion between cardiologist and diabetes researcher Mikhail Kosiborod, MD, and family physician Neil Skolnik, MD, on where treatment of type 2 diabetes with the class of sodium-glucose cotransporter (SGLT2) inhibitors should ideally begin

There is a faction that feels initiation should be in primary care, where preventive medicine is at the heart of practice.

There is a greater chorus of voices that includes Drs Kosiborod and Skolnik that says first, no class of drugs belongs to one specialty or another and second, that care for the patient with type 2 diabetes, takes a village--the paradigm should be team-based multidisciplinary care.

The conversation begins with an examination of the state of preventive care in the US.

Kosiborod, a cardiologist, and Skolnik, a family practitioner, agree no single specialty owns that prescription and that "it takes a village to care for a patient." 

Diabetes Type 2

Where Should SGLT-2 Inhibitor Therapy Begin? Thoughts from Drs Mikhail Kosiborod and Neil Skolnik 

"Drugs don't belong to specialties. They ultimately belong to the patients who take them," said renowned cardiologist and professor of medicine Mikhail Kosiborod, MD, during an interview with Patient Care Online. 

Kosiborod and Neil Skolnik, MD, professor of family and community medicine and well-known primary care educator, spoke together with Patient Care about how and where the sodium glucose contransporter-2 (SGLT-2) inhibitor class of medications are being prescribed, and whether their full range of potency against cardiometabolic disease is fully appreciated yet, across specialties and in primary care. 

What emerged in this first of a 3-part interview between a primary care physician and a cardiology specialist is that SGLT-2 inhibitors are not your grandparents' diabetes drugs and that traditional compartmentalization of drugs, diseases, and patient types serves neither patient or clinician. 

For the second part of this interview, please see: 

is Professor of Medicine, University of Missouri Kansas City, Vice President, Research, Saint Luke’s Health System, Executive Director, Cardiometabolic Center Alliance, Director, Cardiometabolic Research and Co-director, Haverty Cardiometabolic Center of Excellence, Saint Luke’s Mid America Heart Institute, Kansas City, MO. 

 is Professor of Family and Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

Mikhail Kosiborod, MD, a cardiologist and Neil Skolnik, MD, a primary care physician, agree that whoever is seeing the patient should prescribe the drug that is needed. 

SGLT-2 Inhibitors Belong to Patients, Not a Specialty or Primary Care: Experts Discuss 

Patients with type 2 diabetes (T2D) who remain above recommended glycemic targets are at increased risk for a myriad of well-known complications, elevating the importance of early, aggressive treatment.

, Sridharan Raghavan, MD, PhD, assistant professor of medicine in the Department of Medicine at the University of Colorado Anschutz Medical Campus, reviews the findings of a study he recently led on trends in timing of and A1c level at initiation of second-line therapy among US veterans newly diagnosed with type 2 diabetes.

The findings reinforce the subtle but steady erosion in therapeutic progress driven by clinical inertia in US health care.

For more of Patient Care's conversation with Dr Raghavan, please see:

Delay in Second-line T2D Treatment Among Younger US Veterans Sparks Investigator Concern

VA Clinical Investigator Discusses HbA1c, Comorbidities as Markers for T2D Treatment Intensification

is an assitant professor and clinical investigator in the division of hosptial medicine, University of Colorado Denver, Anschutz Medical Campus and a clinician at the Rocky Mountain Regional Veterans Affairs Medical Center in Aurora, Colorado.

Reference: Raghavan S, Warsavage T, Liu WG, et al. 

Trends in timing of and glycemia at initiation of second-line type 2 diabetes treatment in US adults. 

Diabetes Care. Published online ahead of print March 28, 2022;dc212492. 

Initiation of second-line type 2 diabetes treatment is lagging while A1c at the time it is introduced is climbing. The author of a new study highlights his findings on clinical inertia. 

Study Author Reviews Results: Trends in Time to Initiation of Second-line T2D Treatment 

Treatment intensification for patients with type 2 diabetes (T2D) already on a regimen of daily basal insulin is a difficult transition – for both the patient and the clinician rendering care, observed Brian Levy, MD, in a recent conversation with Patient Care Online. 

The transition to basal plus mealtime insulin increases daily injections from 1 to 4 for the patient and adds complexity and risk to patient management for the clinician—one barrier for each party to gaining better control of hyperglycemia.

But that’s just 1 barrier among many for both patient and clinician, Levy, an endocrinologist and clinical assistant professor of medicine at NYU Grossman School of Medicine, told Patient Care. So-called 

 is multifactorial and can delay T2D treatment intensification by more than 4 years.

In the interview that follows Levy sketches a clinical profile of the patient with T2D who now needs to add mealtime insulin. He talks candidly about the psychosocial and logistical factors that slow clinical progress and cites evidence of how some patients struggle. 

 is an endocrinologist and clincial assistant professor of medicine at New York University Grossman School of Medicine in New York, NY. 

The following transcript has been lightly edited for clarity and style. 

. I’d like to ask you to sketch a profile of a patient with type 2 diabetes being seen in primary care who's considered an ideal candidate for bolus mealtime insulin. How long have they had diabetes? What's their medication history, their age, etc? What does the patient look like?

These patients who need to advance from basal insulin to mealtime insulin do tend to have a longer history of diabete

s—on average greater than 10 or 15 years. These patients tend to be overweight, or medically obese. Type 2 diabetes is both a disease of resistance to insulin based on obesity, but also a progressive loss of insulin over time, less insulin produced by the pancreas. So the duration of diabetes at the time when they need insulin is many years longer than for a patient who might be well controlled on a noninsulin therapy. That also presumes that a patient has been over the years on the right treatment paradigm for their type 2 diabetes starting with 1, 2, or 3 oral antihyperglycemic agents and/or injectable noninsulins like the GLP-1 receptor agonist class. These are all great treatments but over time, they may become less effective. The first hurdle is for the patient to be started on a once-a-day basal insulin. Then, after the physician has titrated the basal insulin upwards over time, but patients are still not achieving their glycemic goals (as measured by the hemoglobin A1c test), that is when further intensification, beginning mealtime insulin, is required. These patients might tend to be older because they've had diabetes longer. By older I mean in their 50s and up. But that's not necessarily going to be true in the future because people are developing type 2 diabetes at younger and younger ages, sadly, sometimes as pediatric or adolescent patients. So, the need for insulin may start at a younger age than what we're seeing now.

PCO. Clinical inertia is not a new phenomenon, and it happens across disease states. What tends to be the resistance on the physician side? The physician knows that this is the next right step, but what potentially holds him back?

 There are several physician barriers, especially in the primary care office, where they may not have the same staff, such as diabetes educators, that an endocrinologist might have. And yet, the majority of people with type 2 diabetes are treated in the primary care office simply because type 2 diabetes is so common. One thought that goes through the clinician’s head, though we don’t want it to, is, “If only you (the patient) followed your diet, lost weight, and exercised, you wouldn't need advancement to insulin therapy.” That’s not entirely true. At every step of the way, we want patients to focus on weight control and eating the right foods. So, that’s one barrier that clinicians have. The other well, there are many, but another is it's a lot more work. And it's a lot more time consuming to first initiate insulin. I mentioned that's the first barrier—basal insulin. Even more so, the next barrier is intensification of insulin, from 1 shot a day to let's say, 4 shots a day—3 mealtime shots, plus a basal shot. There is fear on the clinician’s part of new issues such as hypoglycemia and how to manage it, how to teach patients how to manage hypoglycemia. There is the fear of not feeling comfortable with up- titrating insulin doses once the regimen becomes complex. And the list goes on. It’s stressful for the healthcare professional and has a lot to do with lack of time. Dealing with the patient’s other problems, like high blood pressure, heart disease, arthritis.It’s hard in a busy office practice with all their patients having multiple medical issues that they deal with on a daily basis.

PCO. I would think that for the patient there are equally as many barriers. Maybe one of the primary ones being the fear that this means their diabetes is getting worse. They may also be putting out negative energy that meets the clinician’s energy and together it pushes the discussion away from the elephant in the room.

You’re totally right, it's negative energy on both sides. And we have to break those barriers. Patients are afraid that if their insulin is intensified, that means they're sicker. And that's not necessarily true. It means the disease has progressed and requires a different way to manage it to successfully prevent diabetes complications by controlling the blood glucose.

But multiple injections mean many things too many patients. 

They usually take their basal insulin as 1 injection per day, usually in the evening, in the privacy of their own home. Multiple injections mean something quite different; it means taking shots during the daytime, which can interfere with daily activities. Whether that’s being at work at a meeting, or social activities, being in a restaurant, where you have to separate from the crowd to take your insulin, which makes you feel 

 from the crowd. There are feelings of embarrassment. People with type 2 diabetes are already somewhat embarrassed because the disease has a negative connotation. It usually means, “You're overweight and you don't want to eat healthy.” Also, not necessarily true. And then last, but certainly not least, and I don't want to underestimate it, is injection pain. We teach that insulin shots are painless. They are 

painless, but they're not painless. And to go from 1 shot-a-day to 4 shots-a-day for mealtime-plus-basal insulin is a pain issue as well. 

I’d like to bring up a study. This was a survey of a large number of people with type2 diabetes, and it astounded me as a clinician in that 72% of the patients reported that they 

 take their insulin outside of the home. That is a significant number. And the other important number here is that more than half of the patients reported missing injections they knew they should take, or they simply forgot to dose, perhaps at a social event or at a work meeting.

There is another study which has shown that if patients who need a shot at each meal miss 4 of those shots in a week, that’s 4 out of 21 injections a week of mealtime insulin, the result is an increase in their hemoglobin A1c of up to 1%. That's significant.

We spend a large part of our day in a postprandial state, really about 12 hours a day. So, patients with type 2 diabetes need insulin to control how high their sugars go after meals, and they're not taking their shots because of a variety of psychosocial barriers. Glycemic control is going to worsen which puts them at increased risk of developing complications over time.

Type 2 diabetes patients-and their PCPs-may have trouble moving to basal + mealtime insulin from basal insulin alone. Endocrinologist Brian Levy, MD, offers insights.  

Barriers to Intensifying Insulin in T2D Management: An Interview on Clinical Inertia

"...the answer is yes, we do need to be more aggressive in our drug therapy [against type 2 diabetes]. But I think the first thing is to recognize risk early, [for example] to deal with the problem of obesity as a society.

"It is crazy that it is so easy to end up with a BMI of 35 in our society now. We need to have social policy that helps us prevent that."  

 interview, Dr John Buse was emphatic that waging a focused fight against risk factors for T2D is a far more rationale solution than placing one-third of the US population on 3 drugs as first-line therapy against the disease.  

John B. Buse, MD, PhD is Distinguished Professor, Chief, Division of Endocrinology, Director, Diabetes Center, Executive Associate Dean for Clinical Research at the University of North Carolina School of Medicine at Chapel Hill.  

 with Dr Buse on newly reported findings from the GRADE study, including data that seem to favor insulin and GLP-1 RA therapy over a sulfonlyurea or DPP-4 inhibitor; Dr Buse also discusses T2D treatment selection based on comorbidities. 

Diabetes investigator John Buse, MD, PhD, says laser focus on reducing T2D risk factors is equally as important as using the next right drug against the disease. 

At ADA 2021, John Buse, MD, PhD, says US Must Focus on Control of Obesity, Other T2D Risk Factors 

"We always had the primary care providers in mind," said John Buse, MD, PhD, in an interview with 

. "And what I mean by that is that before a patient could be enrolled in this trial, they had to have a primary care provider, the primary care provider had to basically be on board with this four-arm randomization." 

Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study

, preliminary results of which were reported on Monday, June 28, 2021 at a virtual  symposium during the American Diabetes Association 81st Scientific Sessions.

The head-to-head study of 4 classes of commonly used antihyperglycemic agents was the largest and longest study to compare efficacy of routinely prescribed second-line treatment for type 2 diabetes (T2D): a sulfonylurea, a DPP-4 inhibitor, a GLP-1 receptor agonist, and insulin glargine. 

Buse, a member of the GRADE executive committee and involved since inception of the study concept, gave 

 a look inside the study's history and placed the preliminary findings in the context of recently expanded indications for T2D therapies. A seasoned investigator, Buse  called for more head-to-head comparison studies that would help primary care physicians make more informed and more targeted T2D treatment decisions. And, he previews the many new questions the GRADE results have raised about optimal T2D therapy.   

 is Distinguished Professor, Chief, Division of Endocrinology, Director, Diabetes Center, Executive Associate Dean for Clinical Research at the University of North Carolina School of Medicine at Chapel Hill.  

, from our ADA 2021 interview with Dr John Buse on waging a focused fight against risk factors for T2D vs placing one-third of the US population on 3 drugs as first-line therapy against the disease.  

Dr Buse’s in-depth review of the GRADE study is followed by a discussion of the keen need for more comparative research and the many new questions the results have raised about optimal T2D therapy. 

Inside GRADE: Exec Committee Member John Buse, MD, PhD, Toplines Study Results, Calls for More Head-to-Head Research  

"In this day and age...I think you would have to look for a reason not to do it, rather than to look for a reason to do it in patients who have kidney disease." 

SGLT-2 inhibitor investigator Mikhail Kosiborod, MD, answers questions about patient selection for the class of drugs, now with approval to treat much more than type 2 diabetes. 

Nephrology

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