The Multidisciplinary Approach to Managing Patients With CKD
In this video, James Matera, DO, speaks with nephrologist Wayne Kotzker, MD, primary care physician Maria Ciminelli, MD, cardiologist Lance Berger, MD, and nutritionist Jamie Miller, RD, about the role of the multidisciplinary approach in the management of patients with chronic kidney disease (CKD), including referring a patient to a specialist, ensuring risk reduction and slowing the progression of end-stage renal disease, and cardiovascular risk factors in patients with CKD.
Additional Resource:
- The kidney failure risk equation. Accessed March 6, 2023. kidneyfailurerisk.com.
For more chronic kidney disease content, visit the Resource Center.
James Matera, DO, is a practicing nephrologist, Senior Vice President for Medical Affairs, and Chief Medical Officer at CentraState Medical Center (Freehold, NJ).
Maria Ciminelli, MD, is a primary care physician, Chair of the Family Medicine Residency Program at CentraState Medical Center, and Vice Chair of the Rutgers Family Medicine Residency Program (Freehold, NJ).
Lance Berger, MD, is a cardiologist at Monmouth Cardologiy Associates LLC and Medical Director of the Echocardiography Laboratory at Jersey Shore University Medical Center (Neptune, NJ).
Jamie Miller, RD, is a dietitian and diabetes care and education specialist in the Renal and Pancreas Transplant Division at Saint Barnabas Medical Center and an adjunct professor in the Nutrition and Food Studies Department at Montclair State University (Livingston, NJ).
Wayne Kotzker, MD, is a nephrologist at Florida Kidney Physicians and an associate professor of medicine at Nova Southeastern University School of Medicine and Charles E. Schmidt Medical School at Florida Atlantic University (Boca Raton, FL).
TRANSCRIPTION:
James Matera, DO:
Good evening and thank you for joining our roundtable today on our discussion of a multidisciplinary approach to the evaluation and management of patients with chronic kidney disease. I'm pleased to have put together a roundtable of some experts in the field. I'd like to introduce Dr Maria Ciminelli. She is the chair of our family medicine residency program at Centra State and also the vice chairman of the Rutgers Family Medicine Residency Program. Dr Lance Berger is a cardiologist. He's a FACC and he's also the medical director of the echocardiography lab at Jersey Shore Medical Center and recently has an extra credential in cardio-oncology. And Dr. Berger is with Monmouth Cardiology. We have Ms Jamie Miller, who's a registered dietician, particularly in the diabetes and transplant clinic, from Saint Barnabas Medical Center in Livingston. And Dr Wayne Kotzker, who is the clinical leader of value-based care from Florida Kidney Physicians, and he has a number of academic appointments as well.
So ladies and gentlemen, thank you for joining me tonight on what I think will be a very interesting discussion. I'm going to kick it off, kind of open it up to everybody, but what do you see as your role in the management of the chronic kidney disease patient? And let's go ahead and start with Dr Ciminelli as our primary care physician.
Maria Ciminelli, MD:
Sure, thanks Jim. I think first I'd like to say thank you for including me in this great panel, but in terms of chronic kidney disease and because of how prevalent it is in our society and in the United States, I think primary care physicians like family physicians myself need to really be particularly paying attention to those who have risk factors for chronic kidney disease, screening those patients for chronic kidney disease and then managing them in terms of education for the patient in terms of things to avoid in regards to nephrotoxic agents and also in terms of maintaining lifestyle and making healthy choices. And then especially in terms of when to have these patients evaluated by the nephrologist, when is the correct time to refer patients to the nephrologist, and doing the basic workup for those patients, and then including other important people like the dietician for example, and the cardiologist because so many of our patients with chronic kidney disease already have had established cardiovascular disease or are of course at risk for cardiovascular disease.
James Matera, DO:
Yeah, I think those are great points. And Wayne is a compatriot of mine having taken care of chronic kidney disease patients for more years than we care to look at. How about that with the multidisciplinary approach that Dr Ciminelli described? Is that important to you in your work?
Wayne Kotzker, MD:
I definitely agree with what Dr Ciminelli said. And I think that we are seeing chronic kidney disease becoming a primary care disease. In fact, if you look at the numbers, there are roughly 37 million Americans that have some form of chronic kidney disease. And when you look at the numbers of physicians, there are around 9,000 nephrologists and maybe 450,000 primary care specialists. So when you look at those numbers, it becomes overwhelming for a nephrologist to even to be able to take care of early chronic kidney disease. And I think early chronic kidney disease, when I say stage 2 or stage 3a, that's a disease that's being seen and should be certainly identified by a primary care physician.
And I do agree, when you look at the risk factors for patients with chronic kidney disease, they are five times more likely to die a cardiovascular death and progress to end-stage kidney disease. And so for those reasons, you do have to have a multidisciplinary approach. And we certainly as nephrologists can't take care of all those patients. We have to rely on our primary care physicians and our cardiologists and the rest of that interdisciplinary team.
James Matera, DO:
Yeah, I think that speaks volumes. I mean, some of the statistics are overwhelming when I look at them, that a vast majority of our patients who may have even stage 3 and above don't even know that they have chronic kidney disease, so they're not aware of the modifications that they can make. And with the plethora of drugs that we have out there now... We know about the ACEs and ARBs and the SGLT2 inhibitors are certainly coming to the forefront too. So Jamie, what do you think about with a patient like that? And we know we want to catch them early, and what are some dietary things we can do to try to prevent progression in the future?
Jamie Miller, RD:
Yeah, thank you. I think that definitely, especially with the population that I work with, patients with diabetes, of course, diabetes and kidney disease kind of go hand in hand. I see a lot of patients whose cause of renal failure was diabetes and hypertension or both. And if they do have these risk factors, like hypertension and diabetes, taking the steps that they need to in order to manage those conditions a little bit better, counting their carbohydrates for blood sugar control, taking their insulin or other oral medications, controlling their blood pressure. And once they get identified as having chronic kidney disease, they can definitely do some diet and lifestyle modifications to help prevent or delay the need for dialysis.
So certainly following a healthier diet, watching how much protein they're consuming and what types of protein, trying to avoid or limit the red meat consumption and high sodium, ultra-processed foods, all of those things, A plant-based type of approach is definitely a lot more popular nowadays. So working with a dietician to kind of adopt that type of an eating style while also managing their other conditions, especially when it gets to the later stages of kidney disease if they have to watch their potassium and their phosphorus, it becomes a little bit more tricky with some of the fruits and vegetables and the plant-based sources of protein. So working with a dietician is definitely ideal all across the stages of kidney disease. And then of course, if they do end up on dialysis, working with a dietician then too because their protein needs are higher and they are watching that potassium, phosphorus, sodium, all of that. So from my standpoint, as a part of the multidisciplinary team, I think that nutrition obviously does play a pretty big role in the management of kidney disease, for sure.
James Matera, DO:
Yeah, the earlier, the better. And we know, and Dr Berger's going to comment on this now, we know that we try to do the best we can for these patients, but oftentimes their significant factors is cardiovascular disease. And that's where we see the deaths in our population. And we also know things like bone and mineral metabolism and phosphorus control that in the past we thought was just a bone disease, we now know that cardiovascular risk factors play a role too. So Lance, what do you think about that? What can we do, again, as a team to try to lessen those risk factors to try to prevent unnecessary or early deaths in our chronic kidney disease population?
Lance Berger, MD:
Well, thank you so much for having me today. I'm very proud to be here and to share some thoughts about this. And let me first say, Dr Kotzker, that was a great segue into what I think is probably the most critical thing that I can do as a cardiologist or we can do as cardiologists, which is to recognize that our CKD patients that come to us are much more likely to die from cardiovascular disease than even to get onto dialysis. And so recognizing that, I think is the first step in understanding where to go from here.
So, in terms of being able to manage it all, I really do try to get the blood pressure under very good control, typically somewhere in the 120/80 range or below, especially if they have chronic kidney insufficiency. I try to get their lipids under control so their cholesterol... With the most recent guidelines, especially if they're diabetic with CKD, I'm going to try and shoot for that LDL below 55. And dietary changes, typically, I would recommend either the DASH diet or Mediterranean diet or some combination thereof, but because of the concerns about the specifics in CKD, I need a dietician as part of the team to help me get to get through that, especially since the DASH diet does recommend higher potassium type foods.
And exercise and a healthy lifestyle I think is really essential for people to help get their blood pressure under control and to control their risk factors as well. It really does take a multidisciplinary team. But recognizing the patients that come to me for evaluation who have chronic kidney disease, educating them about their risk factors is of critical nature of how we approach that, monitoring them through and collaborating with their primary care doctors, with their nephrologist if they have them, referring them to nephrology if necessary, and a dietician. I think we can really put a team together around somebody to try and mitigate their risk moving forward for cardiovascular disease, and potentially reduce their risk for dialysis.
James Matera, DO:
Those are all great points, and I love the fact that we all agree that we need to surround this patient with the team. So Wayne, as a nephrologist, how do you work with the care team? So what are some specific things you do to coordinate with the cardiologist, the dietician, the primary care to ensure that the patient is being taken care of? We see our patients every couple of months, and then they're out there seeing other docs. What are some of the things you do specifically to try to coordinate care?
Wayne Kotzker, MD:
Well, I think obviously communication is very, very important. And certainly, I try to educate when I see a consultation coming from my primary care physician, about the things that would rely on the primary care physician to be doing, such as the types of screening and testing. And not just for the one patient I'm seeing, but that they can then extrapolate to other patients like that patient that they're seeing, such as screening for urine albuminuria, monitoring lab tests, and then of course discussing issues that I think do affect and do benefit the patient. You started to mention ACE and ARB. You mentioned SGLT2 inhibitors. We have several new medications that are down the pipeline that are coming. So it's very important that my primary care physicians know that those medications can be used and can be used early to address the needs for their patients.
And then in those situations where I have a patient obviously being co-managed by a cardiologist, communicating with the cardiologist in terms of what we think their risks are and what we need to be addressing. And I do oftentimes advise my patients to see a dietician and nutritionist to get them on the right diet that addresses not only the chronic kidney disease, but those other comorbidities that they have to manage, specifically making sure that their diabetes is well controlled, that they're watching the right diet. Because it's easy enough to say, "You need to be on a low protein or low sodium diet," but then as Dr Berger pointed out, the DASH diet focuses more on higher potassium content. Or a patient who's a diabetic who might look at a more low-protein diet may then start to substitute carbohydrates, which would not be appropriate in a diabetes situation.
Our patients are very, very complex. And I think the biggest thing is, like you said, we have to focus on a multidisciplinary strategy where we're working together as a team and that the patient can feel that I'm not countering what the cardiologist said, I'm not countering what the primary said, that we're all on the same page, and we're all trying to work with the patient to improve their overall quality of life, and as we said, delay the progression to end-stage kidney disease and hopefully reduce their cardiovascular mortality.
James Matera, DO:
Yeah, it's a good point. As I think back to some of the interactions we used to have with cardiologists, and as nephrology fellows, we were taught that if the cardiologist said that they're wet, they were obviously dry, and if they were dry, they were obviously wet. Those days are gone and we need to work together. Maria, one of the things that I always think that primary care docs get concerned about... Or what are those red flags? What are those things that we need to know from the nephrologist that would amp that up? Or in specifically, what are some things you look for to say, "I know we need to get the patient to a nephrologist"?
Maria Ciminelli, MD:
Sure. Well, as Wayne was saying, those patients who have early chronic kidney disease in stage 3a or lower, or better function I should say, we are seeing them all the time. We need to manage those. Because as he said, there are way more primary care physicians than there are nephrologists. So in those patients, I want to make sure that I'm prescribing the right medicines in terms of reducing the progression of the disease, whether it be the ACEs and the ARBs, the SGLT2 inhibitors, and now even adding the GLP-1 agonists as well. But in terms of the red flags, for me, certainly if it's somebody in the early stage of disease who then still has persistent albuminuria of greater than 300 after I've put them on an ACE and ARB, I'm going to send them to the nephrologist for sure. Those patients who have any indication of rapid decline in their CKD, certainly for those more than 25% reduction or in a year more than four milliliters per minute per year of reduction of their estimated GFR, I'm going to be really concerned, and I'm going to get them to the nephrologist.
I like to use evidence-based risk calculators, so maybe even kidneyfailurerisk.com in terms of seeing what their risk is for getting to renal failure sooner. So, especially for somebody who's young whose kidney disease is going to be for a longer period of time, we hope, I might get them to the nephrologist a little bit earlier. Certainly, for those patients who have a family history of significant chronic kidney disease whose family members have been on dialysis and who are progressing, I certainly would be concerned about that. For patients who have red cell cast in their urine, I'm going to ask for my nephrologist to see them sooner rather than later. Those who have persistent abnormalities in their potassium, that even though I get them to see the dietician, they are eating a lower potassium diet, I start them on management for that and I still have issues in terms of the potassium, I'm certainly going to get my nephrologist to see them sooner rather than later. And then certainly anybody with GFR of less than 30 has to see the nephrologist.
James Matera, DO:
And I think that's a good thing because I think studies do show that getting them to the nephrologist earlier because Dr. Kotzker and I know that education... And I know in particular, he, like I, is very interested in home therapies, which I think do change the course of that, so earlier education. So Jamie, we've talked a lot about diet, and I think sometimes you have the hardest job because you have to sit with the patient and tell them why they can or can't eat different things. How do you achieve success with that? How do you get the patient to buy in?
Jamie Miller, RD:
Yeah, that's a really good question. And I do agree that sometimes my job can be pretty hard because we do love our food, and potentially taking something away from someone who's so accustomed to having something can be disheartening to the patient and make them angry. The approach that I like to take is nothing is completely off-limits. I really like to sit down with them, get a really nice detailed diet history from them. Typically, they're prescribed by their nephrologist or primary care. It's a specific type of diet, like low-sodium, lower-protein, low-potassium. So based on the diet prescription that they're provided by the physician, I then go through their typical day of eating. "Walk me through from the time you wake up to the time you go to sleep. What's a normal day of eating for you, breakfast, lunch, dinner, snacks, beverages, all of that?'
I also like to get a deeper history in terms of who does their grocery shopping and cooking. What's their access to food like? Do they have any food allergies, intolerances, or cultural things that impact the foods that they choose? And then I like to go through the foods that they actually eat or what their typical meals and snacks are like and suggest modifications that they can make in order to help improve their renal parameters like the potassium if they're struggling with it or phosphorus, or if we're swapping out different types of protein. I like to get a real feel for their preferences and the types of things that they're eating and what they like. That way it's more realistic for the patient because it can be really tricky following multiple dietary restrictions, especially for our patients who do have diabetes, and they have to watch their carbohydrates. And along with that, now they're being told that they have to reduce their protein intake.
So really being empathetic and compassionate does help. And also just working with them to figure out, okay, how can we fit this food in? Or you might be decreasing the frequency at which you have certain things or the portion. Nothing is completely off-limits. But overall, your best interest is our focus here, and following the diet, the dietary restrictions can hopefully help them feel better and if they aren't on dialysis, help them to hopefully prolong the need for dialysis. And that usually can be pretty motivating for patients.
James Matera, DO:
Yes, it can. No doubt about that. That's great. And I'm glad you brought up social determinants of health and food insecurities. That's something that we're really going to be involved in in the coming years. This was a very, very good discussion. I'd like to ask anybody for any closing comments.
Maria Ciminelli, MD:
Dr. Matera, I think as a family physician, for me, prevention is most important. So, I know Dr Berger talked about all of those modifications in regard to cardiovascular risk reduction. One of the most important ones that I focus on certainly is smoking cessation. So any patient, we didn't mention that yet, but smoking cessation is a big one that I take into account. In addition, Jamie mentioned cultural issues involved in diet, but also the primary person who does the cooking and who does the shopping in the home. So for me as a family physician, that's one of the first things I ask. And I bring those people in, whether it be the wife of my 60-year-old with CKD and diabetes who does all the cooking and the shopping so that she hears the message from me. And then when I refer him to the dietician, make sure that she goes along with him so that the most important people are there in terms of getting that information.
James Matera, DO:
Fantastic. Any other comments from the group?
Lance Berger, MD:
Well, thank you for mentioning cigarette smoking. I think that's an essential part. And I can summarize what I mentioned earlier by a simple ABCDE mnemonic, that we are aware of the interaction between chronic kidney disease and cardiovascular disease, that we are maintaining blood pressure control pretty tightly in these folks. The C would be cholesterol management and cigarette smoking. D would be control their diabetes and dietary modifications. And E, exercise and other elements of a healthy lifestyle. I think that sort of summarizes how I approach this in very simple alphabetical order.
James Matera, DO:
Absolutely. Great points.
Lance Berger, MD:
I think if we can continue that with all the patients that we see and address each one of those bullet points, I think it will impact outcomes dramatically. And thank you for the opportunity to discuss this.
James Matera, DO:
I think the complexity of our patients, and Wayne you could vouch for this too, necessitates this approach. I think sometimes people get afraid of the chronic kidney disease patient, and that's okay. But I think we have to realize that these patients are not just chronic kidney disease patients. Sometimes that's the easier of the management constructs. So Wayne, any final comments?
Wayne Kotzker, MD:
I think this is a great discussion, and I think it really does demonstrate that this is certainly a multidisciplinary approach. And I think you made the point that prevention of dialysis or when patients get to that point, when we talk about dialysis, interesting how that can be a motivating factor. And just speaking to dietary modification, I've had patients that get to stage 4 kidney disease, and that's when they decide to go on a plant-based diet. And it's amazing how they can delay years from actually progressing to end-stage kidney. If we can have that impact earlier upstream, I think the amount of impact that'll have cardiovascular as well as progression of CKD. So I think that dietary modification is huge. And then as you said, I think earlier on intervention. I sometimes say to my primary care physicians, "If you employ ACE, ARB, SGLT2 inhibitors, GLP-1, you do these medications and lifestyle modification in 3a or 2, they may never come to my office, and that's okay.
James Matera, DO:
Yeah, I agree. One of the things that we haven't talked about here before we close is we talk about all these medications, but sometimes it could be cost-prohibitive to the patients to be on a lot of these things. So that's something that we have to work with in general as we look at all the social determinants of health, food insecurities, home insecurities, and cost insecurities. So those are things we'll have to look at. We have the tools. We have to make sure that they're employed correctly.
Wayne Kotzker, MD:
Well, it speaks to if we can do the lifestyle modification and the dietary modification early enough to have that much of an impact, then yes, we'll be able to hopefully avoid some of those more costly tools.
James Matera, DO:
Totally agree. All right, everyone, I would like to thank you for a very great and inspiring communication and roundtable here, and thank you all for your time. And I hope everybody enjoys this. Have a good night.
Wayne Kotzker, MD:
Thank you.
Lance Berger, MD:
Thank you.
Maria Ciminelli, MD:
Thank you