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Physicians' Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physicians' Education Resource®, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Acknowledgment of Commercial Support

This activity is supported by an educational grant from Bayer HealthCare.

Medical Crossfire®: Understanding the Complexities of Chronic Kidney Disease in Type 2 Diabetes

Release Date: October 31, 2019
Expiration Date: October 31, 2020
Media: Internet - based

Activity Overview

The overall prevalence of chronic kidney disease (CKD) in the general US population is approximately 14%. Diabetes and hypertension are the leading causes. Diabetic kidney disease (DKD) may already be present when type 2 diabetes (T2D) is identified in patients. It is a silent killer, and symptoms do not manifest until more than 90% of renal function is lost. The annual mortality rate associated with kidney disease is greater than breast or prostate cancer. Unfortunately, early interventions are impeded by alarmingly low screening rates, underdiagnosis, and minimal patient awareness. Almost half of individuals with CKD also have cardiovascular disease. Cardiovascular disease risk factors such as hypertension, obesity, and hyperlipidemia multiply a diabetic patient’s demands on their kidneys, as well as elevate their risks of renal and diabetes complications.

Early diagnosis of DKD allows clinicians to optimize drug therapy to prevent progression to end-stage renal disease and aggressively manage comorbidities and complications. Although there has been little progress in the last decade for developing new treatment options for CKD, newer classes of glucose-lowering agents have demonstrated renoprotective effects and novel nonglucose-lowering agents are emerging.

During this Medical Crossfire®, a multidisciplinary panel will discuss the impact of CKD in patients with diabetes, from risk factors to guideline-based screening recommendations, followed by renoprotective strategies with new and emerging agents. A series of patient cases with increasing severity of kidney disease will exemplify the treatments and strategies for improving patient outcomes.

Benefits of Participating

  • Gain a better understanding of the complex interplay between metabolic abnormalities and kidney disease
  • Review the latest guidelines for screening and diagnosis of CKD
  • Learn how to optimize renoprotective treatments through case presentations
  • Increase awareness of treatments that have the potential to impact patient outcomes

Acknowledgement of Commercial Support

This activity is supported by an educational grant from Bayer HealthCare.

Instructions for This Activity and Receiving Credit

  • You will need to log in to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review videos/content until you finish the presentation.
  • At the end of the activity, “Educational Content/Video” will be available for your reference.
  • In order to receive a CME/CE Certificate, you must complete the activity.
  • Complete the Posttest and pass with a score of 70% or higher, complete the Evaluation, and then click on “Request for Credit.” You may immediately download a CME/CE Certificate upon completion of these steps.

Target Audience

This online educational activity is directed toward primary care physicians, endocrinologists, nephrologists, nurse practitioners, physician assistants, and other health care professionals who treat patients with T2D.

Learning Objectives

Upon successful completion of this educational activity, you should be better prepared to:

  • Describe recommended diagnostic practices for CKD in patients with T2D.
  • Recognize the complex pathophysiology of CKD and the role of mineralocorticoid receptors in disease progression.
  • Evaluate the efficacy and safety of nonsteroidal mineralocorticoid receptor antagonists and other therapies under investigation for treatment of patients with CKD.

Faculty, Staff, and Planners’ Disclosures

Faculty

Stephen Brunton
Stephen Brunton, MD, FAAFP
Primary Care Metabolic Group
Murrieta, CA
Adjunct Associate Professor
Touro University California
College of Osteopathic Medicine
Vallejo, CA

Disclosures: Consultant: Advisory Board for Abbott Diabetes, Acadia, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Janssen, Merck, Mylan, Novo Nordisk, Xeris, Genentech; Speakers Bureau: AstraZeneca, Boehringer Ingelheim, Janssen, Lilly, Novo Nordisk.

George L. Bakris
George L. Bakris, MD
Professor of Medicine
Department of Medicine
Director, American Heart Association Comprehensive Hypertension Center
University of Chicago Medicine
Chicago, IL

Disclosures: Grant Research Support: Bayer, Vascular Dynamics-paid to University of Chicago; Consultant: Merck, Relypsa, AstraZeneca, Vascular Dynamics

Harold Bays
Harold Bays, MD, FOMA, FTOS, FACC, FACE, FNLA
Medical Director and President
Louisville Metabolic and Atherosclerosis Research Center
Louisville, KY

Disclosures: Grant Research Support: In the past 12 months, Dr Bays' research site has received research grants from AstraZeneca, Boehringer lngelheim, Bristol-Meyers Squibb, Eli Lilly, Gan and Lee, GlaxoSmithKline, Home Access, iSpecimen, Janssen, Johnson and Johnson, Merck, Novo Nordisk, Pfizer, Qualigen, and Takeda.

Lucia M. Novak
Lucia M. Novak, MSN, ANP-BC, BC-ADM, CDTC
Director
Riverside Diabetes Center
Riverside Medical Associates
Riverdale Park, MD

Disclosures: Consultant: Novo Nordisk, Sanofi, Abbott; Speakers Bureau: Novo Nordisk, AstraZeneca, Janssen, Abbott.

PER uses a blinded peer review process.
The peer reviewer discloses the following: Peer reviewer has no relevant financial relationships with commercial interests to disclose.

The staff of Physicians' Education Resource®, LLC (PER®), have no relevant financial relationships with commercial interests to disclose.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, PER® makes it a policy to ensure fair balance, independence, objectivity, and scientific rigor in all its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines relevant financial relationships as financial relationships in any amount occurring within the past 12 months that create a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only and is not meant to substitute for the independent clinical judgment of a physician and a nurse relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER®.

PER Pulse™ Recaps

1 of 3

Medical Crossfire®: Understanding the Complexities of Chronic Kidney Disease in Type 2 Diabetes. In this certified continuing medical education (CME) activity, multidisciplinary experts George Bakris, MD, Harold Bays, MD, Stephen Brunton, MD, and Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC, engage in panel discussions to share insights on screening frequency and risk factors for diabetic chronic kidney disease. Faculty then cover the latest treatment guidelines and renoprotective strategies with existing and emerging treatment agents, culminating in a series of patient case studies to apply the most up-to-date treatment approaches in scenarios involving increasing severity of kidney disease.

This first of 3 PER Pulse™ Recaps focuses on the metabolic abnormalities of type 2 diabetes (T2D) that promote development of chronic kidney disease (CKD), and on how frequently kidney function should be screened in patients with diabetes. Some key points are below.

  • CKD, one of the greatest clinical challenges of managing patients with T2D, significantly increases patients’ risk for cardiovascular disease, retinopathy, and other diabetic complications.1
  • Diabetes can encompass multiple metabolic abnormalities—including hypertension, hyperglycemia, and immunopathies—that impact the kidneys and other organ systems.
  • Almost 50% of patients with CKD also have cardiovascular disease. Cardiovascular disease risk factors, such as hypertension, obesity, and hyperlipidemia, further heighten physiologic demands on the kidneys, elevating nephropathy risk.
  • Diabetic kidney disease is already present when T2D is diagnosed, in many cases.
    • Earlier diagnosis allows for treatment to prevent progression of kidney disease.
  • The American Diabetes Association’s Standards of Medical Care in Diabetes recommend screening for CKD at least once a year with urinary albumin and estimated glomerular filtration rate (eGFR) in all patients with T2D and all patients with comorbid hypertension.1
  • Frequency of monitoring depends on severity of disease. If microalbuminuria is present (30-300 mg/g urinary albumin) and the patient’s eGFR is <60 mL/m/1.73m2, then monitoring with greater frequency is necessary.2
    • The KDIGO Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease provides a chart recommending frequency of monitoring by eGFR and albuminuria category.2

“Microalbumin can be thought of as the kidney C-reactive protein because microalbumin tells you about inflammation. You may not have kidney disease or microalbuminuria, but [elevated microalbumin indicates] you have increased leakiness of the kidney, and that means there is inflammation somewhere. And multiple, multiple analyses have shown higher cardiovascular risk in people with microalbuminuria, not because they have kidney disease but because they have underlying inflammation.”3
‒ George Bakris, MD

References

  1. 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes−2020. American Diabetes Association. Diabetes Care. 2020;43(Suppl 1): S135-S151. Available at:/care.diabetesjournals.org/content/43/Supplement_1/S135. Accessed: January 2, 2020.
  2. Levin A, Stevens PE, Bilous RW, et al. Kidney Disease: Improving Global Outcomes (KDIGO) CKD work group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3(1):1-150. doi: 10.1038/kisup.2012.73.
  3. Bakris GL, Molitch M. Microalbuminuria as a risk predictor in diabetes: the continuing saga. Diabetes Care. 2014;37(3):867-875. doi: 10.2337/dc13-1870.

2 of 3

Medical Crossfire®: Understanding the Complexities of Chronic Kidney Disease in Type 2 Diabetes. In this certified continuing medical education (CME) activity, multidisciplinary experts George Bakris, MD, Harold Bays, MD, Stephen Brunton, MD, and Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC, engage in panel discussions to share insights on screening frequency and risk factors for diabetic chronic kidney disease. Faculty then cover the latest treatment guidelines and renoprotective strategies with existing and emerging treatment agents, culminating in a series of patient case studies to apply the most up-to-date treatment approaches in scenarios involving increasing severity of kidney disease.

This second of 3 PER Pulse™ Recaps focuses on the complex pathophysiology of the kidney and renoprotection in chronic kidney disease (CKD). Some key points are below.

  • The kidney is a hemodynamic, vascular, and regulatory organ that is pressure-sensitive, such that changes in pressure will affect kidney function as kidney disease progresses.
    • Electrolyte concentrations are also regulated by the kidney.
  • The renin–angiotensin–aldosterone system (RAAS) regulates blood pressure and systemic vascular resistance to influence cardiac output and arterial pressure.
  • Agents that block the RAAS can offer renoprotective effects in patients with type 2 diabetes (T2D) by lessening effects of aldosterone, which is known to accelerate renal damage by sustaining cell growth, inflammation, and fibrosis within the kidney.1,2
  • The presence of heart failure, CKD, or T2D, as well as the use of RAAS inhibitors, increase the risk of chronic or recurrent hyperkalemia.
    • Predictors of hyperkalemia include an estimated glomerular filtration rate <45 mL/min/1.73 m2 and serum potassium >4.5 mEq/L.

“One of the reasons patients don’t feel well is because their bicarbonate, while maybe in the reasonable range, is too low. And we now know that if you have advanced kidney disease and the bicarbonate is below 23 [mEq/L] you actually should give sodium bicarbonate. Patients will feel better and it increases the longevity of kidney function.”
– George Bakris, MD

References

  1. Remuzzi G, Cattaneo D, Perico N. The aggravating mechanisms of aldosterone on kidney fibrosis. J Am Soc Nephrol. 2008;19(8):1459-1462. doi: 10.1681/ASN.2007101079.
  2. Bolignano D, Palmer SC, Navaneethan SD, Strippoli GF. Aldosterone antagonists for preventing the progression of chronic kidney disease. Cochrane Database Syst Rev. 2014;(4):CD007004. doi: 10.1002/14651858.CD007004.pub3.

3 of 3

Medical Crossfire®: Understanding the Complexities of Chronic Kidney Disease in Type 2 Diabetes. In this certified continuing medical education (CME) activity, multidisciplinary experts George Bakris, MD, Harold Bays, MD, Stephen Brunton, MD, and Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC, engage in panel discussions to share insights on screening frequency and risk factors for diabetic chronic kidney disease. Faculty then cover the latest treatment guidelines and renoprotective strategies with existing and emerging treatment agents, culminating in a series of patient case studies to apply the most up-to-date treatment approaches in scenarios involving increasing severity of kidney disease.

This third of 3 PER Pulse™ Recaps highlights novel nonsteroidal mineralocorticoid receptor agonists (MRAs) for treatment of patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). Some key points are below.

  • Steroidal mineralocorticoid receptor antagonists (MRAs) can increase the risk of hyperkalemia when given with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs).
  • A new family of nonsteroidal MRAs may overcome the limitations of steroidal antagonists.
  • In a phase II study of patients with diabetic nephropathy, most on ACE inhibitors or ARBs, the addition of finerenone, the nonsteroidal MRA, improved the urinary albumin-to-creatinine ratio, compared with placebo.1
  • Finerenone is being evaluated in 2 parallel, randomized, double-blind, placebo-controlled phase III trials including more than 13,000 patients with T2D and CKD.2,3

“In patients who are overweight or obese, [decreasing] inflammation and free fatty acids is important [to prevent] diabetes, hypertension, and to some degree dyslipidemia, but the endocrinopathies also play a big part of the adverse consequence of the adiposity or the sick fat. Mineralocorticoids act on both the endocrinopathies and inflammation, as opposed to many other agents we use for metabolic diseases for their anti-inflammatory effects.”
‒ Harold Bays, MD

References

  1. Bakris GL, Agarwal R, Chan JC, et al; Mineralocorticoid Receptor Antagonist Tolerability Study–Diabetic Neuropathy (ARTS-DN) Study Group. Effect of finerenone on albuminuria in patients with diabetic nephropathy: a randomized clinical trial. JAMA. 2015;314(9):884-894. doi: 10.1001/jama.2015.10081.
  2. Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and the Clinical Diagnosis of Diabetic Kidney Disease (FIGARO-DKD). clinicaltrials.gov/ct2/show/NCT02545049. Updated December 12, 2019. Accessed December 24, 2019.
  3. Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and Diabetic Kidney Disease (FIDELIO-DKD). clinicaltrials.gov/ct2/show/NCT02540993. Updated December 12, 2019. Accessed December 24, 2019.

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