The number of Americans with end-stage kidney disease more than doubled between 2000 and 2019. Poorly controlled diabetes and high blood pressure are driving the increase. Hypertension control rates have recently fallen to 44% while the benchmark for the best medical care is 90%. Optimal medical therapy achievement in diabetes is equally poor. This is especially frustrating because we have the tools to dramatically slow this problem now. Only one sixth as many patients with type 2 diabetes and chronic kidney disease progress to dialysis on optimal medical therapy (OMT) compared with usual care—the care that most people in America receive. OMT for diabetes and hypertension is systematic and it can be scaled and spread. Special operations primary care teams manned by nurse practitioners, pharmacists, and physician assistants can make a huge difference now.
This increase in progression to dialysis matters to every American. “The continued increase in the number of ESKD cases will increase strain on the health care system and lead to higher costs,” the authors wrote. Patients on dialysis consumed 7% of all Medicare spending. Our system is really crazy. Because we do not provide access to primary care for everyone and implement best practices backed by a mountain of evidence to manage diabetes and high blood pressure, the number of patients going on dialysis continues to increase with an especially severe impact on minorities and the disadvantaged. Huge disparities based on race and economics persist. Over this time period, progression to dialysis among Asian Americans increased by 150%.When I practiced in Beaufort SC there were 4 dialysis clinics in that one county and 90% of them were African Americans who did not receive best practice treatment for their diabetes and hypertension. This is a common problem impacting one in 400 Americans.
We can reverse this trend now and reduce suffering and cost for thousands of Americans by developing primary care teams focused on cardiometabolic disease now. These teams can reduce progression to dialysis based on science that was available in 2008. We can do even better now by adding SGLT2 inhibitors as the second drug in diabetes management after metformin and spironolactone or eplerenone as the fourth medication in hypertension management.
This information is especially important for the people who pay the bills for medical care like accountable care organizations and MedicareAdvantage plans. Slowing progression to kidney failure also reduces heart attacks, strokes, and amputations and the costs of those events.
Only 10% of Americans with chronic kidney disease even know they have it. If you have diabetes or high blood pressure, ask your doctor about being tested.
Aren't those conditions preventable - at least to a degree - by following a healthy diet, exercising, no smoking, and minimal drinking?