QUALITY INITIATIVES
Increasing Urine Microalbumin Testing
Elevated urine albumin is a well-established risk factor for adverse outcomes including kidney disease progression, yet is often not assessed. We work with partners to address potential barriers to testing.
Prescribing of GLP-1 Receptor Agonists & SGLT2 inhibitors
New classes of medications have been shown to improve glucose control, decrease mortality, slow chronic kidney disease progression and support weight loss.
BACKGROUND
Approximately 15% of adult Americans have chronic kidney disease (CKD) – representing over 35 million Americans. This equates to more than 1 million people with CKD living in Michigan, where kidney disease is also the 8th leading cause of death. There exist many barriers to optimal management of CKD, including the fact that most patients are asymptomatic and unaware of their kidney condition. Yet fundamentally much of kidney disease is preventable by patient actions thus, intervening early to increase patient engagement with providers and prevent progression of CKD is critically important.
CKD is a heterogeneous disease. While some kidney conditions require targeted therapy (e.g. immunosuppression regimen for glomerulonephritis), in most cases, CKD is caused by upstream modifiable factors, e.g. Diabetes Mellitus and high blood pressure. As such, there are mainstays of preventing kidney disease and its progression for many that include controlling blood pressure; risk factor modification (e.g. glycemic control in diabetes); preferential use of angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB); and avoidance of nephrotoxic exposures.
Despite available guidelines, the most recent Medicare data show that only 71% of patients with diabetes and CKD are on an ACEI or ARB, and little significant improvement has been made over the past decade. In addition, use of some nephrotoxins (e.g. NSAIDs) in patients who have CKD has been on the rise.
This important kidney centric CQI will specifically address opportunities to improve care for patients with chronic kidney disease who have type 2 diabetes, with the goal of slowing progression and preventing new onset of CKD. Further, it will set the stage for optimizing provider recognition and equipping providers with support tools so that they have what they need to deliver evidence-based, best practices seamlessly at the time of care delivery.
Areas of Impact
Our overall goal is to reduce the incidence and progression of kidney disease among residents of Michigan. To achieve this goal, we will focus initially on the following areas:
- Increase awareness around kidney disease by promoting testing for urine albumin in at-risk patients. Elevated urine albumin is a well-established risk factor for adverse outcomes including kidney disease progression, yet is often not assessed. We will work with partners to address potential barriers to testing.
- Increase use of newer treatments for diabetic kidney disease, such as SGLT2 inhibitors and GLP-1 agonists. We will provide educational support and resources to partners, and help to increase accessibility to newer therapies.
Disparities
Worldwide, the US ranks among the top five countries for incidence of End Stage Kidney disease. [1] Chronic Kidney Disease is a poster child for disparities by race, ethnicity, geography and socioeconomic status. Despite its high burden (~15% of the adult population of the US; i.e., more common than diabetes mellitus), awareness of kidney disease is low at 10%. [2] This means that while 1 in 7 US adults have CKD, on average, only 1 in 10 of those who have it by laboratory criteria, are even aware of it. [2] Infrequent urine testing for albuminuria is common even among those identified with major risk factors such as diabetes and hypertension. [1] CKD is predominantly a disease of older adults, although a significant problem among young people and children. The race/ethnicity groups in the US with the highest incidence of CKD and ESKD include African Americans, Native Hawaiian and Pacific Islanders and Hispanics [3-6]. Multiple hotspots of the disease exist in the US and in the state of Michigan. Social determinants of health (poverty, racism, food insecurity, etc.), and environmental factors (e.g., air pollution, heat and toxin exposure) may play a significant role in perpetuating disparities in kidney disease.
Bibliography
- United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.
- Centers for Disease Control and Prevention. Chronic Kidney Disease Surveillance System—United States. website: https://nccd.cdc.gov/CKD/
- Crews DC, Bello AK, Saadi G; World Kidney Day Steering, Committee. Burden, access, and disparities in kidney disease. J Nephrol. 2019 Feb;32(1):1-8. doi: 10.1007/s40620-019-00590-6. PMID: 30707401.
- Laster M, Shen JI, Norris KC. Kidney Disease Among African Americans: A Population Perspective. Am J Kidney Dis. 2018 Nov;72(5 Suppl 1):S3-S7. doi: 10.1053/j.ajkd.2018.06.021. PMID: 30343720; PMCID: PMC6200351.
- Xiang J, Morgenstern H, Li Y, Steffick D, Bragg-Gresham J, Panapasa S, Raphael KL, Robinson BM, Herman WH, Saran R. Incidence of ESKD Among Native Hawaiians and Pacific Islanders Living in the 50 US States and Pacific Island Territories. Am J Kidney Dis. 2020 Sep;76(3):340-349.e1. doi: 10.1053/j.ajkd.2020.01.008. Epub 2020 May 5. PMID: 32387021.
- Albertus P, Morgenstern H, Robinson B, Saran R. Risk of ESRD in the United States. Am J Kidney Dis. 2016 Dec;68(6):862-872. doi: 10.1053/j.ajkd.2016.05.030. Epub 2016 Aug 28. PMID: 27578184; PMCID: PMC5123906.
LEARN ABOUT URINE ALBUMIN TESTING
The presence of albumin in the urine is one of the earliest signs of kidney disease, and may precede any signs of kidney function decline that can be identified by bloodwork. Therefore, testing for urine albumin is an important screening tool for patients at risk for kidney disease, such as those with diabetes. By identifying kidney disease at its earliest stages through urine albumin testing, clinicians have the best opportunity to intervene and prevent – or even reverse – kidney disease. Yet urine albumin testing remains significantly underutilized. MKIC aims to improve awareness around testing for urine albumin as a way to achieve the broader goal of reducing the overall burden of kidney disease.
LEARN ABOUT SGLT2is AND GLP-1 RAs
One of the key initiatives in the Michigan Collaborative for Type 2 Diabetes is increasing prescribing of SGLT2 inhibitors and GLP-1 receptor agonists. These medications improve glucose control, decrease mortality and adverse cardiovascular events, slow progression of chronic kidney disease, & support weight loss.
What are sodium glucose cotransporter-2 inhibitors (SGLT2is)?
SGLT2is are a class of glucose-lowering drugs that work by preventing the reabsorption of glucose from the blood that’s filtered by the kidneys, therefore facilitating glucose excretion in the urine. SGLT2is are widely used to treat patients with type 2 diabetes who are not well controlled on metformin alone. SGLT2is have the added benefit of protecting the heart and kidney health through the reduction of cardiovascular events and slowing of renal failure progression. SGLT2is also help patients lose weight.
What are glucagon-like peptide-1 receptor agonists (GLP-1 RAs)?
GLP-1 RAs are a class of glucose lowering drugs that work by stimulating the release of insulin by the pancreas after eating, inhibiting release of glucagon by the pancreas, which prevents the liver from releasing stored sugar into the bloodstream. GLP-1 RAs also slow glucose absorption into the bloodstream by slowing gastric emptying after eating. GLP-1 RAs significantly improve cardiovascular and renal outcomes, as well as help patients lose weight.
Why SGLT2is AND GLP-1 RAs?
In order of intensification, the paradigm of care for type 2 diabetes treatment historically has been diet and exercise, followed by Metformin, and then polypharmacy with basal insulin. Advances in care and scientific evidence in the last 20 years has provided a firm foundation that this paradigm is no longer the best course of treatment for patients with type 2 diabetes and in fact leads to further disease progression as well as adverse outcomes and complications.
Innumerable scientific studies have shown that there are far better options than the paradigm discussed above. Two new classes of medications, Sodium-glucose Cotransporter-2 (SGLT2is) Inhibitors and Glucagon-Like Peptide 1 Receptor Agonists (GLP-1 RA) represent much more effective second line treatments after Metformin alone. These classes of medications both significantly reduce glucose levels, reduce glycemic variability, and result in clinically significant weight loss. Weight loss from these medications represents a juxtaposition in clinical trajectory from disease worsening to reversing the underlying cause of type 2 diabetes.
OUR VISION
The MCT2D Kidney Initiative seeks to engage and empower medical providers and patients across the state of Michigan to support the dissemination and implementation of evidence-based strategies that will prevent and slow the progression of kidney disease.
KIDNEY RESOURCES
UPCOMING KIDNEY EVENTS
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ccteam@mct2d.org
Support for The Michigan Collaborative for Type 2 Diabetes (MCT2D) is provided by Blue Cross and Blue Shield of Michigan as part of the BCBSM Value Partnerships program.
Although Blue Cross Blue Shield of Michigan and MCT2D work collaboratively, the opinions, beliefs and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs and viewpoints of BCBSM or any of its employees.