Pamela Kushner, MD, FAAFP 

Optimizing Multidisciplinary Collaboration in CKD Management

In the final episode, ‘Optimizing Multidisciplinary Collaboration in CKD Management,’ the panelists explore the following critical questions:

How do you collaborate with other multidisciplinary clinicians, such as cardiologists, nephrologists, endocrinologists, primary care, to ensure coordinated CKD identification and follow-up?

What advice would you like to share with colleagues about implementing both uACR and eGFR testing to support earlier CKD diagnosis and cardiovascular risk management in clinical practice?

Led by the moderator, the experts conclude by addressing the challenge of maintaining a continuum of care between infrequent clinical visits, identifying the EHR as the critical "common denominator" for aligning primary care, cardiology, and endocrinology on a unified plan. Dr. Kushner stresses the importance of explicit clinician-to-clinician communication and detailed "SOAP" plan documentation to prevent therapeutic inertia during the months between specialist consultations. A major highlight of the discussion is the expanded role of the pharmacist in executing "de-congestion" strategies, such as remote medication titration, which allows physicians to focus on diagnostic complexity while ensuring patients reach guideline-directed doses.

The panel also underscores the necessity of patient empowerment, suggesting that showing a patient their position on the KDIGO heat map can bridge the literacy gap and foster shared decision-making. Final pearls from the experts reinforce that the "science is clear" and the current therapeutic armamentarium offers a unique opportunity to change the trajectory of CKD if caught early. By embracing a "know your numbers" campaign for uACR and fostering a community of healthcare responsibility, the panelists argue that clinicians can meaningfully delay or even prevent the progression to end-stage renal disease, providing patients with a significantly higher quality of life.

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Learn how uACR and eGFR tracking, EHR prompts, and team-based titration streamline early CKD care and reduce cardiovascular risk.

Clinical and Biomarker Signals for Escalating Therapy in High-Risk CKD

This episode, titled, ‘Clinical and Biomarker Signals for Escalating Therapy in High-Risk CKD,’ features panelists discussing the following critical question:

What clinical or biomarker-based signals prompt treatment modifications or escalations in patients with CKD and elevated cardiovascular risk?

Led by the moderator, this discussion explores how clinicians can use "responsive" biomarkers to combat the "silent" nature of early-stage CKD and keep patients engaged in their care. Much like HbA1c in diabetes or LDL-C in lipid management, the panel suggests that tracking uACR provides a visual feedback loop that proves a drug is working, specifically aiming for the ADA-recommended 30% reduction. Dr. Desai and Dr. Kushner explain that this feedback is essential for shared decision-making, allowing clinicians to tailor the "starting therapy" based on a patient’s unique profile—such as prioritizing GLP-1 receptor agonists for a patient with obesity or SGLT2 inhibitors for those with heart failure with reduced ejection fraction (HFrEF).

The experts also contrast the "race to four drugs" seen in heart failure with the longer-term horizon of CKD, suggesting that while the ultimate goal remains comprehensive cardiorenal protection, the sequencing of medications can be a collaborative, incremental process. By framing uACR reduction as an improvement in systemic endothelial health and a decrease in cardiovascular risk (as reflected in updated PREVENT scores), clinicians can move from a "one-size-fits-all" recipe to a nuanced, patient-centered strategy. This approach is particularly effective for patients with a family history of dialysis, where the motivation to intercept disease progression is high, making the "fun part" of clinical practice the integration of evidence-based guidelines with personalized patient goals.

In the last episode, ‘Optimizing Multidisciplinary Collaboration in CKD Management,’ the panelists advocate for transforming the CKM care pathway by leveraging electronic health records (EHR) as a universal platform for trust and communication among primary care and specialist teams. They emphasize a multidisciplinary "team-based" approach—utilizing pharmacists for titration and telehealth for monitoring—to ensure that the momentum of early diagnosis is maintained throughout the long-term journey of chronic disease management.

See how UACR trends motivate patients, guide shared decisions, and tailor therapies to slow CKD while lowering cardiovascular risk.

Tailoring CKD Management to Cardiovascular Risk and Multidisciplinary Monitoring

In ‘Tailoring CKD Management to Cardiovascular Risk and Multidisciplinary Monitoring,’ our experts delve into the following critical questions:

How does the management strategy for patients with CKD and T2D change based on their cardiovascular risk profile?

How do cardiology and nephrology perspectives differ in monitoring therapeutic response in CKD, particularly with respect to reliance on eGFR alone versus combined eGFR and uACR assessment?

Drawing from successful implementation strategies in heart failure, Dr. Desai argues for a paradigm shift in CKD care toward simultaneous initiation of the "four pillars" of therapy. This approach moves away from the traditional model of maximizing one drug before adding another, instead prioritizing early, comprehensive coverage to capture synergistic benefits across the cardiorenal metabolic spectrum. The experts note that because these therapies often target the same high-risk patient population—those with obesity, diabetes, and hypertension—clinicians have a unique opportunity to simplify complex regimens into a core group of multi-organ protective agents.

The discussion also details the logistical requirements of a follow-up visit, which must balance disease monitoring with medication onboarding. Dr. Beavers outlines a dual-track monitoring system: tracking eGFR and uACR progression according to the KDIGO heat map's risk levels, while simultaneously managing the aggressive monthly titration schedules required for newer agents like GLP-1 receptor agonists. The panel concludes that while the initial onboarding phase requires frequent assessment (often within one month of starting therapy), the predictable response of biomarkers like uACR provides a reliable metric for clinicians to gauge treatment success and ensure long-term stability.

Our next episode, ‘Clinical and Biomarker Signals for Escalating Therapy in High-Risk CKD,’ further explores chronic kidney disease, highlighting the transition of uACR from a diagnostic tool to a responsive biomarker, emphasizing its value in providing patients with tangible evidence of treatment success. They highlight that achieving at least a 30% reduction in uACR is a key clinical goal that not only confirms renal protection but also serves as a motivator for long-term adherence to complex, individualized therapy regimens.

Heart failure playbook reshapes CKD care: early combo therapies, right dosing, and smart uACR/eGFR follow-up to boost adherence.

Approaches to Prioritizing and Sequencing Therapies in CKD

In this episode, ‘Approaches to Prioritizing and Sequencing Therapies in CKD,’ the panelists explore the following questions:

What role do angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), sodium-glucose cotransporter 2 (SGLT2) inhibitors, non-steroidal MRAs, and GLP-1 receptor agonist play in your treatment decisions for patients with CKD in patients with T2D and other comorbidities?

How do you prioritize and sequence therapies for patients with CKD?

This segment explores the operational challenges of implementing the modern quadruple therapy framework for chronic kidney disease, particularly in the overlap of type 2 diabetes and CKM syndrome. Dr. Kushner highlights a common clinical pitfall: the failure to titrate RAS inhibitors to their maximum tolerated doses, noting that sub-therapeutic dosing significantly limits the potential to slow disease progression. To improve adherence, the experts suggest a practical communication shift—explicitly labeling prescriptions with the medication's purpose (e.g., "for slowing kidney disease progression") to help patients understand the systemic protection these drugs provide beyond mere symptom management.

The experts also emphasize the necessity of evolving care models to include pharmacists and mid-level providers who can focus on the intensive work of dose optimization and navigating insurance access barriers. Dr. Beavers introduces the concept of "de-prescribing" less effective medications to reduce pill burden and make the core guideline-directed medical therapy (GDMT) more tolerable for the patient. By combining motivational interviewing with shared decision-making, the panel argues that clinicians can align these complex therapeutic regimens with the patient’s personal health goals, ultimately moving toward a more sustainable and effective management strategy.

The next episode in this series, ‘Tailoring CKD Management to Cardiovascular Risk and Multidisciplinary Monitoring,’ features the experts advancing their conversation on chronic kidney disease. The panelists apply foundational principles from heart failure management to CKD, emphasizing that early "upstream" combination therapy—starting low-to-intermediate doses of multiple drug classes simultaneously—is more effective than slow, sequential titration. They suggest that long-term adherence can be improved by reframing these treatments as a unified regimen that simultaneously targets weight, glycemia, and cardiorenal protection.

Explore the four-pillars approach to slowing kidney disease—max dose ACE/ARB, add SGLT2, MRA, GLP‑1—plus access and team-based tips.

Pamela Kushner, MD, FAAFP

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