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What: Live Expert Panel on Managing Obesity in Kidney Disease

To promote high-quality, person-directed care across the spectrum of kidney health and diseases, the American Society of Nephrology (ASN) is releasing its inaugural Kidney Health Guidance (KHG) on the Management of Obesity in Persons Living with Kidney Diseases in the on September 18, 2024.

Reporters are invited to this live event on Obesity Management and Kidney Health where experts from the American Society of Nephrology will take questions on the inaugural Kidney Health Guidance on managing obesity in kidney disease patients. The report will discuss new strategies and tools for healthcare professionals to address obesity sensitively and effectively, aiming to improve patient outcomes and kidney health through a comprehensive, evidence-based approach.

Who: 

• Deidra C. Crews, MD, ScM, FASN, President of the American Society of Nephrology
• Holly J. Kramer, MD, MPH
• T. Alp Ikizler, MD, FASN

When: Monday, September 16, 2024 at 12:15 PM ET

Where: 麻豆传媒 Live Zoom Room (address will be included in follow-up email)

Moderator: Hello and welcome to this 麻豆传媒 Live Event. Thank you to members of the media who have joined and thank you to all of our panelists here with the American Society of Nephrology that have joined us to talk about the new guidance on kidney disease and obesity. I'd like to start by inviting here Dr. Crews, the president of the American Society of Nephrology, to introduce yourself and where you work, and tell us a little bit about what the ASN hopes to accomplish with this new guidance.

Dr. Deidra Crews: (0:38) Great. Thank you. Thom, so Hi everyone. I'm Deidra Crews. I'm a nephrologist at Johns Hopkins University in Baltimore, and as was said, I'm the current president of the American Society of Nephrology. And we are very excited about this launch of our new kidney health guidance, with the first one being focused on obesity for people living with kidney diseases, the impetus really behind us, even starting this initiative of putting forward kidney health guidance was really identifying that despite there being a number of different bodies that put together guidelines that focus on the way that we provide care for people with kidney diseases. It was identified that there was a space that our organization could fill in trying to produce what would be fairly, short, or shorter forms of guidance that really could get into some of the various practice considerations that clinicians, including nephrology or especially nephrologists who are caring for people with kidney diseases might have and questions that they may be grappling with in terms of what either therapies or behavioral approaches that they may promote for their patients. And so we set out to sort of establish this initiative really around kidney health guidance, and this is the very first one. And so we are super excited about this being published later this week. So yeah, and then this particular topic, certainly we felt like was a timely one where a number of clinicians are having their patients come to them with questions about what the best approach would be for them, whether it's medical therapy or behavioral therapy, lifestyle modifications. What role does their sort of family history, play in how they may respond to some of these different treatments? What role does their stress level and sort of psychosocial factors play in their ability to be able to lose weight and maintain their weight at a healthy weight, and so all of these things really led us to think that this was a great topic to begin our kidney health guidance with. 

Moderator: (3:04) Thank you, Dr. Crews, I'd like to now invite Dr. Ikizler, please introduce yourself and where you work, and tell us about some of the key messages in this guidance and how that's going to help clinicians to treat patients. 

Dr. Alp Ikizler: (3:17) Hi, my name is Alp Ikizler. I'm a nephrologist, Professor of Medicine and the Director of the Division of Nephrology and hypertension at Vanderbilt University Medical Center Nashville. I had the privilege and honor of being a co chair with one of my colleague, Dr. Kramer this initial, first illegal guidance of kidney health guidance for ASN. What we've tried to do in this specific guidance is Dr. Crews, explained, is to promote high quality, personally directed care across the spectrum of kidney health and diseases, along with ASN and obesity, was the management of obesity in persons with gender with kidney disease respect as the first one. We have a couple of different key messages from this guidance. I'm just going to list them out pretty quickly. One of them is that management obesity requires a team based approach and a combination of multiple interventions that have been either already established or developing to achieve a sustainable, safe, healthy weight that is suitable for patients, age, gender, and comorbid conditions. Those who would like to make sure that upfront, a shared decision making is extremely important in terms of when we manage obesity in the setting of kidney diseases. In the patients with kidney disease, we encourage a comprehensive and ongoing assessment that includes consideration of red rate, risk assessment and other things. And then we also are providing a really good clear picture of the advancements in the tools to treat obesity, and these include, but are not limited to anti obesity medications, as well as metabolic and reactive surgery. On top of what’s been established through lifestyle modifications. But then we also would like to achieve, as the final word, to let the physicians that take care of patients with kidney disease to gain the proficiency and prescribing these anti obesity accommodations, and then subsequently making sure that they're monitored appropriate for efficacy and safety. And I would like to finish up with the important emphasis that this is a teamwork and that, you know, we want everyone that has an enrollment in the care of patients, including, but not limited to nurses, dieticians, social workers, advanced providers and others to really get involved in this care.

Moderator: (5:51) Thank you. Dr Kiesler, I'd like to now introduce Dr. Kramer, please tell us about yourself and where you work, and tell us if you could please a little bit more about this guidance and how this is going to differentiate the guidance about obesity and kidney disease from other kinds of clinical guidance.

Dr. Holly Kramer: (6:14) Thank you. It's great to have everyone here to talk about a really important problem for our patients, and I am a nephrologist, a clinical nephrologist at Loyola University of Chicago, and I also have an appointment in public health sciences. So I kind of straddle those two fields of nephrology plus public health and obesity has always been a really important topic to me, because early in my career, I saw many young women who had BMIs  in the 40s, starting dialysis in their early 40s. And I remember my good friend Susan Ho saying to me that this is unusual, and that in her 20 years of being a nephrologist, and this was her in the early 2000s she had never seen such young people with diabetes start dialysis so young. And we had many of these people, and we would go on to see them not be able to get transplanted because their BMI was too high to be waitlisted, not being able to lose weight because really didn't have any kind of interventions to really help these people other than lifestyle modification and and we and we really saw them suffer. So I'm just so excited to see all of the guidance statement, and the group that came together to truly advocate for the nephrology community to address obesity as a major risk factor for CKD progression and for access to transplantation. And I really think that the guidance statement is something that's an ideal issue, right? Because it depends on your resources within your health system about whether or not you have all of these tools that can be used to treat people who have obesity that is impairing their ability to prevent CKD progression, preventing them from living their life optimally, preventing them from getting access to transplantation. So I think that the whole guidance statement is just really meant to kind of really raise awareness, get physicians to implement the tools that we have, whatever tools are available to them, to try to implement them, and to really initiate a discussion with their patients with empathy, communicate with empathy and provide individualized approaches to obesity. So I think what the guidance statement is really all about. And happy to answer any questions

Moderator: (8:27) Members of the media, please do feel free to chat your questions, and I will ask them to the panel for you. Also, just please note that this information is under embargo until Wednesday the 18th, at 12pm when the document for the guidance becomes available to the public. Doctors, I want to bring up something that's obviously made a lot of news and is a key part of the guidance, and that's the obesity drugs, the GLP-1 agonists, that many people have heard of covered in the news. How much does this factor into the new tools that are available for clinicians to help people to manage and treat obesity so as to prevent or worsen the risk of or lessen the risk of kidney disease? Doctor, Dr. Crews, what would you have to say about these GLP-1 agonist, and how they factor in,

Dr. Deidra Crews: (9:21): Yeah, and I certainly will have let my colleagues add to this, but I would say they factor heavily in, I think, into this picture. I think there's been a lot of excitement about the studies that have come out showing the benefits of these, medications in terms of their certainly their ability to help people to lose weight, but also how they, through studies for people with kidney diseases showing that treatment with these can actually lead to slower progression of kidney disease as well as reductions in cardiovascular outcomes. And so I think there's a great amount of excitement around these therapies. There's still, though, a number of challenges around making sure that they're getting to everyone who might benefit from them. There's still not everyone, even people who have insurance, who have even private insurance, or not everyone is able to, get these medications at an affordable cost. And so there's still a lot of work and advocacy to be done around that. There is still some clinical inertia around prescribing these therapies as well, and so these are things certainly that weighed heavily in this report. So I will turn to doctors, Kramer and Ikizler, to sort of add to that.

Moderator: (10:42) Dr. Ikizler, the affordability, the accessibility of these GLP-1 agonists. This is obviously a challenge. We've heard news about the shortages, celebrities taking them to lose weight when they don't really necessarily have an obesity problem. This is obviously all making it more complicated for those that truly need it. What are your thoughts about policy and the direction forward there?

Dr. Alp Ikizler: (11:04) Yeah.Thank you. Thom I think this is an excellent question, an excellent segue, and why this is such an important and appropriate choice for the initial guidance document. And Nephrology is a very complex and comprehensive discipline, and I think people question is to say why obesity was picked as the first guidance document subject, and I think I cannot think of a better choice simply because of multiple things that Dr. Crews has mentioned. One is this excitement of medications that have a direct, I'm not saying indirect, but direct impact on patients living with kidney disease. Having these drugs available to the general public, I think, is even more important than general public to our patient population is cheap. So we will have an opportunity to really make a huge difference in the overall patient population in every disease. And I would like to mention that people might think these drugs and management obesity has impact on diabetic kidney disease and so on so forth. But this extends beyond that and impacts patients with their mother diseases, persistent kidney disease, genetic kidney diseases. So there's a huge impact. That's number one. And number two is that I would say there's a quite a bit of relevance in terms of access to these medications for minority groups. As you know, black Americans have much higher risk with obesity, and that really has a specific impact in terms of hearing access to these medications, but in terms of the medications, availability, policy and everything else, when people read this document, they will recognize that it's a little bit perturbing. We really shoot for the moon to really tell what's the best for our patients. They understand and recognize that this is not practical at this time, especially because of the fact issues that you've pointed out. But we want this to happen. We want this to be a good tool for the policy makers, physicians, providers and others, to take as an example and say, This is what should be done for the best care of our patient population. So since this is an unprecedented opportunity for us, it really could make a big impact. I'll let Dr. Kramer add to that from her own perspective, but my excitement is, I'm really, really excited. That's what I'm going to say.

Moderator: (13:36) Dr. Kramer, what would you like to add about the GLP-1s?

Dr. Holly Kramer: (13:40) I would just say, you know, cost is never dynamic, right? I mean, cost always tends to go down over time. So maybe it might not be available now, it eventually will be. And there's more and more drugs that are coming on the market. So I think, you know, it's really good for physicians to get familiar with how to utilize them, because the cost isn't always going to be an issue.

Moderator: (14:08) We have a question in the chat here from Nancy Melville, freelancer, about the GLP-1s. Are there key areas among clinicians prescribing differences that should be considered in GLP-1s with people with kidney disease versus not kidney disease. Dr. Kramer, differences between people with kidney disease and not.

Dr. Holly Kramer: (14:27) Yeah. So I would put the analogy to kind of a way that we treat gout in chronic kidney disease is start low, go slow, and we emphasize that in the guidance document, to try to emphasize that, we probably need to start with, you know, lower doses, and when you're escalating, that's when you tend to have most side effects. And people with kidney disease may be more sensitive to the escalation of the doses, and so just go slower with it, is what we stated on if you have anything else to add to that, AI

Dr. Alp Ikizler: (15:00) Yeah, yeah. I think this is an excellent question. I totally agree that being slow and being really individualized and personalized in therapy is key. But I also would like to answer the question very specifically, yes. There are two specific patient populations that we have to be very careful about. One is the patients with advanced kidney disease. Please do understand that these drugs still primarily by work by decreasing food intake. There are a lot of metabolic and polytrophic effects of the medications that are under study. We do not know, but there's a quite a bit of note. I won't say side effect, but expect the effect of decreased food intake, inability to eat and digest. And patients with a nice kidney disease, especially those on dialysis, requires special attention in terms of their nutrient intakes and how that really impacts the overall nutritional balance and to avoid risk for other nutritional abnormalities. That's number one. I'm not saying they should not get it. We just need to be very careful, and future research is absolutely necessary. The other one that I would say is critically important is patients with transplantation, and that patient population also represents a very unique profile in terms of the medications that they take, the way they absorb and the way they metabolize, and how food really makes an impact in this medication profiles, especially if you have time to discuss if you combine this anti obesity medications with metabolic bariatric surgery, which could be very effective in these people, especially in terms of access to transplantation, we have to pay further attention and to the answer to the side effects to be worse or better. That is under study. It's not studied yet. I cannot speculate, but I highly encourage for funding. You know the funding mechanisms to provide funding, especially drug companies, not to go with this nihilism of not studying patients with anti kidney disease, but provide resources for us to study these people.

Moderator: (17:09) Nancy, had a further question about the side effects. Dr. Kramer, I'd like to throw that to you. Are the side effects any worse or better for patients with kidney disease and anything clinicians should be aware of there?

Dr: Holly Kramer: (17:20) I don't know about worse or better, you know, side effects, or side effects, like if you feel nauseous and you know, you know, or if you get dehydrated, you know, everyone is going to feel that, but, I think that patients with kidney disease might be more at risk for that, you know, especially like if they're taking diuretics on top of it, you know. So just like outside, you have to really be cautious and make sure that the patient's getting the nutrients that they need, that they don't get volume depleted, you know. So we recommend that they work with a registered dietician, you know, and be monitored. And also, you know that you combine these medications with lifestyle modification so that they eat a healthy diet, you know? And Dr. Crews has always been such an advocate for our patients to eat healthier. And so it's not just the drugs, right? We need to get our patients to eat a healthy diet, and that healthy diet combined with these medications can help them lose weight safely.

Moderator: (18:24) Dr. Crews, if you would tell us more about the lifestyle modification portion of this guidance, this is the first step for many patients and doctors recommending to them that a healthier diet is an important first step toward solving obesity as an issue. These drugs obviously help with that, but it's not a miracle cure necessarily. Tell us about your thoughts about how that's a factor in this guidance.

Dr. Deidra Crews: (18:54) Yeah. Thank you so certainly, despite the excitement that you can certainly hear among us about these new therapies, these new medications. Certainly, we know that  a healthy diet is going to be the most sustainable way, both for in terms of the individual's practices and also for the planet. It's the most sustainable way for us to really think about keeping people healthy, including keeping their kidneys healthy. And so certainly, an important part of this guidance is really, kind of underlining the importance of lifestyle modifications, including dietary modifications, to help people achieve and then sustain the weight that they may be looking to get to. And I think along with that, that it's important for the teams that are caring for such individuals to to assess their ability to actually access the types of foods that we might encourage people to consume in order to help them achieve a healthy weight, and to maintain that and that means, in some cases, connecting them to resources so that they actually can access healthy foods. We know really broadly in the house of medicine that's a problem, that issues like food insecurity really do drive a lot of the disparities that we see in a number of chronic diseases, including kidney disease. And so we know that certainly plays a role in what we see in terms of the high rates of obesity that we see in this country, as well as the high rates of obesity that we see among people living with kidney diseases. So really that that has to be a part of the assessment, and then the therapeutic plan for people with kidney diseases and obesity.

Moderator: (20:37) Dr. Ikizler, another follow up question here from Nancy Melville, are there any important contraindications of GLP-1s, any cases where they should not go that route?

Dr. Alp Ikizler: (20:48) So there's one well established side effect, which is a personal or family history of medullary thyroid cancer, which is in the black box, as well as personal or family history of multiple endocrine neoplasia, which we call MEN2, those are the primate well known convoy indications. Individuals with gallbladder disease or previous history of pancreatitis should not be using the medication either. So those are very well described in the general population, in patients with diabetes and obesity, I would say one of the criteria that I put for patients with kidney disease, especially ones with moderate divest kidney disease and overt findings for nutritional abnormalities, for nutritional state, I think we should probably do not put those patients on these medications unless there's a specific, proven reason to do so. This is my own recommendation that you do not now have these drugs for impact in the overall nutritional state for someone that is already nutrition wasted or at risk for wasted

Moderator: (22:00) Dr. Crews about the point of communicating with empathy. The guidance mentions factoring in socioeconomic conditions, other sorts of marginalized populations, minorities, things like that, that addressing and treating obesity with relation to kidney disease is something that there needs to be more compassion, more empathy, more understanding. And a follow up question from Nancy Melville pointing out that there are studies that show that clinicians, whether they realize it or not, or mean to or not, do show some bias toward patients. And I think that with obesity, that's a factor that cannot be ignored. So what does that mean? What does that mean for clinicians to be working compassionately and empathetically to treat obesity?

Dr. Deidra Crews: (22:52) Yeah, thank you for that. And absolutely, there is a body of literature really showing that many people with obesity in when they are being seen in clinical settings, they are often stigmatized are not necessarily spoken to with compassionate language. Often are spoken to with language that kind of blames them for their situation with respect to their weight. And we know that that can certainly weed. It's not productive for patients. For one, it's not, certainly a way of compassionately caring for people, and it's not going to help with achieving the goal that ultimately, the both, certainly the patients and their clinicians may have for them, which is weight loss, right? And so really approaching these sort of discussions with a lot of humility and just sort of asking questions about things like, you know, what has that individual tried in terms of when they've been trying to address their weight? What are some of the challenges that they may be facing and really being open and not judgmental around, what the way that people may relay their experiences with their weight and their sort of efforts around weight loss, and I think that that is really critical. And there is, as we've talked a bit about, some of the racial and socioeconomic disparities that exist really around both obesity and Kidney Diseases. There's also a body of literature showing that clinicians, even clinicians from some of these same socially, historically socially marginalized groups may have in their interactions with patients, may also use either stigmatizing language or more judgmental language. And so there is still a lot of work that needs to be done around training clinicians to be better about that in these efforts that we may undertake to try to support people in their efforts to lose weight.

Moderator: (24:51) Dr. Kramer, would you weigh in a little bit on this empathy question about how clinicians can make sure to be supporting their patients and offering them the right advice without that sort of judgmental or blaming aspect to it that Dr. Crews mentioned,

Dr. Holly Kramer: (25:06) Sure, so in the guidance statement, we do talk about avoiding the term obese and obesity, avoiding the term fat, and to really just talk about weight but when you talk about weight management, it should be tied in with a goal. So you know, is it okay if we talk about your weight as a factor that we can address for slowing kidney disease progression or getting you wait listed for a transplant or improve your morbidity? Right? It needs to be tied in with something that is important to the patient. And of course, addressing obesity should always be done with shared decision making, and talk with empathy with your patient. And so I think one of the first things to also think about is don't just start talking about, you know, the weight with the patient. Ask first ,say, is it okay if we talk about your weight as a factor in your kidney disease progression, something that we can address that could help you slow kidney disease progression or help you gain weight listing for transplant, etc, etc. So ask the patient if it's okay to discuss it.

Moderator: (26:17) Dr. Kramer also, if you could tell us more about what kinds of policy issues are related to the points in this guidance, and what should clinicians be aware of in that regard?

Dr. Holly Kramer: (26:30) Well, certainly, as we talked before about the cost of the medications, the cost of multiple medications is always an issue in nephrology. So that would be one policy issue. Another policy issue is the fact that, like, if you have a heart attack, you can get physical rehabilitation. So you can spend, you know, several weeks working with someone who's an exercise, you know, physiologist, working with you to improve your overall health using exercise. We lack that for kidney disease. And I really think, like when someone initiates dialysis,that's even bigger than a heart attack. Why are those patients not being provided with physical rehabilitation, or someone who needs to try to get from dialysis to a kidney transplant, physical rehabilitation and providing them information and counseling on exercise would be extremely beneficial, and of course, it'd be beneficial to help them to lose weight. So we lack funding to get physical rehabilitation for patients with kidney disease. We also lack funding for Nurse Education for kidney disease. So for example, when you're diagnosed with diabetes, you can meet with a nurse educator who will spend time with you, and that nurse educator then is paid by insurance or Medicare. We lack that for kidney disease. We also have an issue with getting enough dieticians, registered dieticians, who have knowledge on obesity and kidney disease, to work with patients who have kidney disease, so only about 10% of patients who have kidney disease that's not treated with dialysis. Ever meet with a registered dietician, even though the Affordable Care Act added no cost sharing for medical nutrition therapy. So we really lack the ability to get these patients hooked up, because many health centers don't have enough registered dieticians who have the expertise in chronic kidney disease, and now we really need people to be with kidney disease and obesity, so we really have a shortage in that issue. So I'm sure there's other policy issues. Dr. Crews would probably know a lot more about this, but those are the ones that come to my mind.

Dr: Deidra Crews: (28:38) Yeah, if I could, I just wanted to add one space that I think we also could use a policy intervention is for those individuals who are considering pursuing trans transplantation but are found to be at a BMI that is above the sort of threshold for the transplant center that they are looking to to be listed at. It's very unclear, from a policy standpoint, whose responsibility it is for that person to be supported in their weight loss, whether it should be the transplant center, or whether it should be the nephrology or the dialysis provider. And so that is a space where, again, where funding is needed, and also clarity around in terms from a policy standpoint about who, who should be taking that on and who should be resourced to to support those individuals. 

Moderator: (29:30) Dr. Crews, the American Society of Nephrology journals are the most respected journals in the nephrology area. How do you anticipate the journal’s readership will react embracing the inclusion of this guidance. 

Dr. Deidra Crews: (29:45) Yeah, well, we're very excited about getting this out in our flagship journals. We refer to it, the Journal of the American Society of Nephrology, in large part because we have heard from our readership in years past that they would be very interested in very clinically relevant, practical sort of reports in our ASN journals. And so we are really particularly excited about this and that and this partnership moving forward to not only have this first guidance document on the management of obesity in people with kidney diseases, but also subsequent kidney health guidance that will be published also in JASN.