Table 2.
Examples of questions patients may ask their clinician/HCP during a clinic visit
| Question | Response guidance for the clinician/HCP |
|---|---|
| 1. Is there a connection between T2D and CKD? | Having T2D is a risk factor for developing CKD. (Things that the patient could do to reduce their risk of developing CKD are noted in the answer to question 5 below.) |
| 2. What other conditions related to T2D can cause or worsen CKD? | In addition to T2D, having high blood pressure (hypertension) and heart (cardiovascular) disease and being obese can increase the risk of developing CKD or worsen CKD |
| 3. What are the possible complications of uncontrolled blood glucose in T2D? | Uncontrolled high blood sugar levels can cause complications such as heart (cardiovascular) disease, CKD, and vision loss |
| 4. What are the stages of CKD, and what do they mean? |
The text in this section assumes that a patient has a very good understanding of CKD already, so if this is not the case for your patient, adjust your language accordingly to ensure understanding. CKD is classified as early CKD (CKD 1 and CKD 2), moderate CKD (CKD 3a and CKD 3b) and advanced CKD (CKD 4 and CKD 5 or kidney failure). Early CKD stages are often asymptomatic, so it is important that the patient asks you or one of their other diabetes care providers about kidney function screening and diagnosis. (As part of the answer to this question, you may want to show the patient Fig. 1ii [4], which gives information on how CKD is staged as well as progression risk.) • CKD stage is typically determined using two approaches (although clinical features and biopsy examination may also be used): (1) by taking a blood sample, processing it, and calculating the eGFR (the eGFR value tells us how well the kidneys are functioning; the higher the value, the better); (2) by taking a urine sample and calculating the UACR (albumin in the urine [albuminuria] suggests kidney damage, so the lower the UACR value, the better) • A person with CKD stage 1 has some kidney damage but with normal or high-level kidney function (UACR < 30 mg/g and eGFR ≥ 90 mL/min/1.73 m2) • A person with CKD stage 2 has some kidney damage with some loss of kidney function (eGFR ≥ 60–89 mL/min/1.73 m2). CKD stages 1 and 2 may be asymptomatic • CKD stage 3 has moderate kidney damage and moderate loss in kidney function and the patient may begin to develop symptoms. Patients may be at CKD stage 3a (eGFR 45–59 mL/min/1.73 m2) or the more advanced CKD stage 3b (eGFR 30–44 mL/min/1.73 m2) • CKD stage 4 is advanced CKD where patients often have advanced kidney damage with a severe decrease in kidney function (eGFR 15–29 mL/min/1.73 m2). It is likely that a kidney transplant or dialysis will be needed in the near future • CKD stage 5 is the most advanced stage and is called end-stage kidney disease or kidney failure (eGFR < 15 mL/min/1.73 m2); at this stage the kidneys have lost almost all function, and dialysis or transplant may be required to sustain life |
| 5. What do you recommend that I know from the very beginning of being diagnosed with T2D as far as risk of CKD? |
(As part of the answer to this question, you may want to show the patient Fig. 1i) High blood sugar levels (hyperglycemia) that occur in T2D can cause harm to the kidneys in just a couple years. Therefore, having an A1C of 7%a (or as recommended by the patient’s HCP) will reduce the patient’s risk of developing CKD. It is also important that they control blood pressure, lose weight if needed, and control cholesterol levels to help reduce their risk of developing CKD. If they start to develop signs of CKD (and CKD is confirmed), there are medications that could slow progression of the disease |
| 6. What kind of medications are used to prevent worsening of CKD? |
• ACEis or ARBs are used for patients with diabetes who have high blood pressure. ACEis or ARBs are also used (up to the maximum tolerated dose) for patients with diabetes, high blood pressure, and albuminuria (UACR ≥ 300 mg/g and/or eGFR <60 mL/min/1.73 m2). Depending on local practice, ACEis or ARBs may also be used for high blood pressure in the absence of albuminuria with or without a T2D diagnosis [6] • SGLT-2 inhibitors are drugs that were initially prescribed to lower blood sugar levels but are now known to have benefits in reducing CKD progression and heart (cardiovascular) events in patients with moderate-to-severely impaired kidney function (eGFR ≥ 20 mL/min/1.73 m2) • Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, will also help reduce CKD progression and heart (cardiovascular) events or can be used in patients unable to use an SGLT-2 inhibitor |
| 7. Where can I get reliable and patient-friendly information about CKD outside of my medical visits? | You may want to write or print out a copy of the following resources for the patient: The National Kidney Foundation (www.kidney.org) and the American Kidney Fund (www.kidneyfund.org) websites offer user-friendly information targeted at all people affected by kidney disease (including CKD) in the USA. Information includes advice about kidney health, risk factors for kidney disease, symptoms, treatment, and testing. The American Kidney Fund notes that they are a leading kidney nonprofit organization that works on behalf of Americans living with kidney disease as well as those at risk of developing kidney disease to “fight kidney disease on all fronts.” The American Diabetes Association also provides patient-friendly information on T2D and associated conditions via their website (www.diabetes.org/diabetes) |
The questions are based on the experiences of the patient coauthors, who noted a lack of effective communication exchange during consultations with their clinician/HCP. The response guidance in the right-hand column of the table is directed to the HCP/clinician and should not be relayed to the patient verbatim, but instead communicated on the basis of the patient’s level of health literacy. Points of note for the clinician/HCP in the example responses are in italics [4, 5, 7, 12–19]
ACEi angiotensin-converting enzyme inhibitor, ARB angiotensin receptor blocker, CKD chronic kidney disease, DCCT Diabetes Control and Complications Trial, eGFR estimated glomerular filtration rate, SGLT-2 sodium-glucose cotransporter 2, UACR urine albumin-to-creatinine ratio, UKPDS UK Prospective Diabetes Study
a50–76% reduction DCCT with A1C of 7% vs 9%; 25% reduction UKPDS with A1C of 7% vs 7.9%