Artificial obstacle to wider use of flosins in kidney patients

Flozins, or SGLT2 inhibitors, are a game changer. They are the drugs that nephrologists have been waiting for. Added to the basic blockade of the renin-angiotensin-aldosterone system, they extend patients' lives by more than a third. Nephrologists haven't had this kind of therapeutic range for a long time. What's more, these are drugs that work at different stages of chronic kidney damage, both in the early and late stages. The less often patients enter post renal failure, the less often they need to take renal replacement therapy. Be the period to reach hemodialysis or peritoneal dialysis or kidney transplantation is simply longer. For these patients, it is donated time.

Since phlozins attached to primary RAA blockade reduce albuminuria and even inhibit it, given at early stages of the disease, they can lead to reversal of changes that have not yet become established in the kidneys. Conversely, by reducing albuminuria in later stages, they influence and fundamentally modify cardiovascular risk in these patients. Because patients with kidney disease don't die from uremia, they die from heart attacks and strokes, that is, from cardiovascular complications. And, unfortunately, they die many times more often than the population without chronic kidney disease.

This is a very big problem, because it turned out that chronic kidney disease is an epidemic walking behind diabetes and behind hypertension. These are two powerful risk groups, where chronic kidney disease is actually embedded in the progression of these diseases, so it walks right behind them, and then adds on with its complications and starts a spiral of very dangerous events. But risk groups also include genetic diseases, polycystic kidney degeneration, glomerulonephritis, tubulointerstitial nephritis, which is often a complication of recurrent urinary tract infections, a number of autoimmune diseases, as well as hematological diseases. That is, the risk groups are many.

Nevertheless, diabetes and hypertension spend our nephrologists sleepless nights because chronic kidney disease is far too rarely detected in its early stages. It should be much more often. Because 9 out of 10 people who have the disease don't know it. If someone doesn't know they have damaged kidneys and should watch out for them, they don't use any prevention. And this is where the phlozines have opened a powerful window for prevention. If we detect kidney damage quickly, at any stage, we are able to act more quickly, so the patient gets the benefit of donated years of life. So this is an effect that cannot be turned a blind eye to.

We should expand preventive measures and increase the detection of chronic kidney disease throughout society, for the reason that we have an armamentarium, a drug that we can offer to our patients, which will contribute not only to the condition of the kidneys, but the entire body and, as I mentioned, affect life expectancy.

Unfortunately, phlazines are not being used on a broad front. Although we nephrologists already have the first phlazine in the form of dapagliflozin, which is also reimbursed for nephrology indications. The reimbursement recommendations are fairly straightforward - there must be a GFR below 60 and above 25 and at least four weeks of treatment with another RAA system-blocking drug, or a documented contraindication to such therapy, and there must be albuminuria. It is written that albuminuria, or ACR, must be above 200 milligrams per gram. And there is a definite catch. We thought it was so simple to determine the albumin/creatinine ratio in a single urine sample, because it doesn't require a daily urine collection. But it turned out to make it very difficult to assign flozins, because not every lab determines ACR and not every individual, let alone the PCP, knows what ACR is at all and will refer the patient to a lab that determines it. This has unfortunately turned out to be a barrier, a prohibitive mechanism. And it can be simplified by not putting a number in the indication of this reimbursement, just indicating that there must be albuminuria or proteinuria. Proteinuria is 80-90 percent albumin. If someone has proteinuria chronically, that means they have albuminuria. And that is enough. To determine albuminuria without a number, a simple strip test is enough, and if it shows albuminuria at 1+, or there is a trace of albuminuria, it means that there are 30 milligrams of albumin per gram of creatinine in the urine, or more. And that is enough.

So we have a drug that prolongs patients' lives, and we are trying to use it as widely as possible. On the other hand, the ACR, which seemed like a very simple test, has proven to be a hindrance to going broadly with this therapy. We also detect chronic kidney disease too late all the time. Coordinated nephrology care should enter primary care. This is slowly happening, but too slowly and we are losing too many people. Many patients will miss out on this therapy, some will receive it too late. Determination of albuminuria in primary care is added to coordinated cardiac and diabetes care will not cover all patients for the reasons I mentioned.

Remember that we are born with two kidneys, some with one, we may have a genetic disease, we may have diseases that fundamentally affect kidney function. It is impossible to live without the kidneys, as they are a powerful factory. Both an endocrine system and a "factory" that affects blood pressure and a powerful detoxification machine. If the kidney becomes diseased, self-poisoning of the body occurs. Of course, we can dialyze the patient with various techniques, offer kidney transplantation (unless there are contraindications), but not all patients will become beneficiaries of this procedure. Kidneys should be respected, saved and examined prophylactically, at least once a year. A general urine test, creatinine and counted EGFR is enough, albuminuria at least determined by a strip test would be useful. For my part, I assure you that we are trying to make the reimbursement indications simpler, so that there would be albuminuria and proteinuria without numbers, so that preventive examinations would be easier in the PCP. Let's make life easier - there is a strip test for albuminuria, which anyone can do at home, just buy it at the pharmacy. If the test shows proteinuria, albuminuria, you need to contact a nephrologist. Then it will be the nephrologist who will consider whether the patient is for deeper diagnostics or for flozin, or whether he should receive extended nephroprotection or a completely different therapy, such as immunosuppressive therapy.