i3 Health is pleased to make this infographic from this activity available for use as a non-accredited self-study or teaching resource. This two module CPE activity brings two leading pharmacists together to discuss the slowing progression of Chronic Kidney disease through value-based care. In Module 1 of this activity, Jeff Sperry, PharmD, BCPS, Clinical Pharmacist at UCHealth Memorial Hospital, will explore risk factors contributing to CKD, efficacy and safety of novel therapies for slowing kidney function decline, and evidence-based strategies for management of CKD complications.  In Module 2 Justin J. Bioc, PharmD, BCPS, BCGP, RPh, Head of Clinical Pharmacy at Devoted Health, will explore the cost-effectiveness of novel therapies indicated to slow kidney function decline and strategies that maximize collaboration between payers and providers to optimize the care of patients with CKD. 

1. All
Stages
Stages
1-2
Stages
2-3
Stages
4-5
End-
Stage
Overall $20,162 $17,969 $19,392 $25,623 $65,142
CKD and
diabetes
mellitus
$22,723 $20,247 $22,007 $29,378
Not
available
CKD and
congestive
heart failure
$31,648 $30,850 $31,301 $37,295
Not
available
Cost of Care
Patients who are Black or African
American, Hispanic or Latino, Asian
American, Pacific Islander, American
Indian or Alaska Native, or Native Hawaiian
or Other Pacific Islander are at an
increased risk for kidney disease.
Disparities
Black or African Americans are 3.4
times as likely, and Hispanic or Latino
Americans are 1.3 times more likely, to
have kidney failure compared with
White Americans.
Medicare Per-Person Spending in 2012
Volume
Overload
Hyperkalemia Metabolic
Acidosis
Anemia
Diabetes
Mineral and
Bone Disorders Hypertension
CHRONIC KIDNEY DISEASE
Jeff Sperry, PharmD, BCPS
Clinical Pharmacist, Internal Medicine
UCHealth Memorial Hospital
Jeff Sperry, PharmD, BCPS, is a Clinical Pharmacist at
UCHealth Memorial Hospital in Colorado Springs, Colorado,
where he practices in both Internal Medicine and in the
medical ICU. He is also a primary preceptor for the Internal
Medicine I & II rotations in the PGY1 residency program.
Dr. Sperry’s clinical interests include anticoagulation,
infectious disease, and pharmacokinetic optimization of drug
therapy. He has presented his research at numerous
professional conferences.
Justin J. Bioc, PharmD, BCPS, BCGP, RPh
Head of Clinical Pharmacy
Devoted Health, Inc.
Justin J. Bioc, PharmD, BCPS, BCGP, RPh, is the Head of
Clinical Pharmacy at Devoted Health, in Waltham,
Massachusetts. He is dual board-certified as a
Pharmacotherapy Specialist and as a Geriatric Pharmacist.
At Devoted Health, he builds clinical programs focused on
improving drug utilization and overall quality.
Dr. Bioc has extensive experience in pharmacy care
management and is a member of the Academy of Managed
Care Pharmacy (ACMP) Professional Practice Committee.
PRESENTED BY:
Dyslipidemia
90%
are UNAWARE that they
have CKD until it has
advanced to a
dangerously late stage
CKD by the Numbers
OF THOSE WHO HAVE CKD:
Bottom line: Individuals older than 65,
that have diabetes, hypertension, or
cardiovascular disease need to be
aware that they can develop kidney
disease, as often there are no
symptoms until late-stage disease.
are over 65
49%
have
diabetes
29%
have hypertension
75%
have cardiovascular
disease
19%
Contributors To and Consequences of CKD
Abnormalities of kidney structure or function present for >3 months with specific implications for health:
eGFR <60 ml/min/1.73 m
Albuminuria (albumin excretion rate >30 mg/24 hours; albumin-to-creatinine ratio >30 mg/g [>3
mg/mmol])
Urine sediment abnormalities (example: red blood cells [RBCs])
Electrolyte and other abnormalities due to tubular disorders
Abnormalities detected by histology
Structural abnormalities detected by imaging
History of kidney transplantation
What Is Chronic Kidney Disease (CKD)?
SLOWING PROGRESSION OF
CHRONIC KIDNEY DISEASE
THROUGH VALUE-BASED CARE
14% of adults in the US have low estimated glomerular
filtration rate (eGFR), albuminuria, or both
2

2. Treatment: Dietary restriction of
phosphate; phosphate binders; avoiding
calcium-based medication; vitamin D
supplementation; for those on dialysis or
severe/progressive
hyperparathyroidism, calcitriol, vitamin
D analogues, calcimimetics
Cause: Decreased renal filtration of
acids, decreased renal
reabsorption of bicarbonate
Treatment: Bicarbonate
supplementation or citrate
supplementation
Acidosis
Indication Canagliflozin Dapagliflozin Empagliflozin Finerenone
Type 2
diabetes
Approved Approved Approved N/A
Heart
failure
N/A Approved Approved Phase 3 trial
Kidney
disease
Approved in type 2
diabetes
Approved Approved
Approved in type 2
diabetes
Control blood
pressure
Goal: systolic blood pressure
(SBP) <120
Control blood
sugar
Goal: hemoglobin A1c
<6.5%-8.5% depending on
severity of CKD and
comorbidities
Control lifestyle
First-line agents
Angiotensin-converting
enzyme inhibitors (ACE-
I)/angiotensin 2 receptor
blockers (ARBs)
Preferred with
albuminuria
Calcium channel blockers
(CCBs)
Thiazide diuretics
Caution: reduced
efficacy with eGFR <30
mL/min/1.73 m
Caution: electrolyte
disturbances
First-line agents
Metformin for all (renally
dose-adjusted)
Sodium-glucose
transporter-2 (SGLT2)
inhibitor
Glucagon-like peptide-1
(GLP-1) receptor agonist
If further glycemic
control required or
unable to tolerate
SGLT2 inhibitor
Healthy eating
Emphasizing fruits and
vegetables, whole
grains, fiber,
decreasing red meat
and sugar, and limiting
sodium to <2 grams per
day
Physical activity
At a minimum:
moderate activity for at
least 30 minutes a day,
most days of the week
Weight loss
Smoking cessation
Contraindications Drug Interactions Renal Dosing
Canagliflozin Dialysis
Insulin, sulfonylurea, meglitinides
(hypoglycemia)
Lithium (decreases lithium
concentrations)
Do not initiate w/ eGFR <30 mL/min/1.73
m (can continue previously
established dose)
Dapagliflozin Dialysis
Insulin, sulfonylureas, meglitinides
(hypoglycemia)
Lithium (decreases lithium
concentrations)
Do not initiate w/ eGFR <25 mL/min/1.73
m (can continue previously
established dose)
KDIGO guidelines suggest eGFR <20
mL/min/1.73 m )
Empagliflozin Dialysis
Insulin, sulfonylureas, meglitinides
(hypoglycemia)
Lithium (decreases lithium
concentrations)
Do not initiate w/ eGFR <20 mL/min/1.73
m (can continue previously
established dose)
Finerenone
Concomitant use with a strong
CYP3A4 inhibitors
Adrenal insufficiency
Severe hepatic disease or
impairment (Child Pugh C)
ACE-I/ARB may increase
hyperkalemia
Initial dose:
eGFR ≥60: 20 mg once daily
eGFR ≥25-59: 10 mg once daily
eGFR <25: not recommended
Adjust maintenance dose based on
potassium
A single patient’s
premiums cannot
cover the cost of
CKD therapies
Changing guidelines
and new therapies
Pharmacy vs medical
benefit design
Anemia
Cause: Decreased production of
erythropoietin in kidneys
Treatment: Intravenous (IV) iron,
erythropoiesis-stimulating agents
(ESAs), daprodustat
Cause: Decreased renal filtration of
phosphate, decreased renal
reabsorption of calcium, decreased
renal synthesis of calcitriol, increased
parathyroid hormone leading to
increased calcium and calcification of
tissues and increased bone turnover
Mineral and
Bone Disorders
Medication to Slow
Kidney Function Decline
Optimizing Parameters
To Slow Kidney Decline
Complications
of CKD and
Management
Challenges To
Coverage Decision
Making
2
2
2
2
2
Cause: Decreased renal filtration of
potassium
Treatment: Dietary potassium
restriction; potassium binders;
dialysis
Hyperkalemia

3. Population health
mindset shift in
managing CKD and
comorbid conditions
Total cost of care in CKD
is important given risk of
complications
Preventing ESRD and
dialysis is a major
priority
Payers want to work
proactively with
providers and patients
to manage CKD
Additional evidence is
needed to determine
comparative
effectiveness
SGLT inhibitors are
widely available and
covered by payers
today
PCP
NAVIGATOR
NEPHROLOGIST
SPECIALISTS
ACUTE/SUB-ACUTE
CARE
COMMUNITY
RESOURCES
DIALYSIS
TRANSPLANT
SOCIAL WORKER
CASE MANAGER
PHARMACIST
DIETICIAN
PATIENT
Payer Perspectives
Shifting to a New Care Model
The Kidney Care Team
Alternative
reimbursement to
address total cost of care
Collaborative and
integrated kidney care
Leveraging of data and
technology to predict
patient outcomes and
connect patients to care
earlier
Increased rates of home
dialysis, transplantation,
and improved patient
outcomes
Wait for patients to crash
into kidney care
Focus on end-stage renal
disease care
management
Large dialysis
organizations control
care and payment
Patients are victims of
cost-cutting measures

4. Future of Multidisciplinary
Collaboration
Focusing on early detection of CKD
Aggressive monitoring and management of chronic conditions and
contributing risk factors for progression of CKD
Virtual and longitudinal care
Capture patient preferences
Navigation to support patients on their journey and everyone in the
know
Helping patients land into the right type of kidney care for them
More real-time or near real-time data sharing
Sustainable strategies for interoperability
Creation and iteration of core value-based metrics for CKD care
Provided by:
Role of the Managed Care Pharmacist
Medication-related education to providers, care teams, and
patients
Medication therapy management
Ensure adherence to evidenced-based therapy
Monitor for adherence and treatment-related toxicity
Recommend dosage adjustments or de-prescribing to
reduce polypharmacy
High number of prescribers involved with patients with
CKD leads to higher risk of polypharmacy
Navigate or promote formulary and coverage requirements
References
Alfego D, Ennis J, Gillespie B, et al (2021). Chronic kidney disease testing among at-risk adults in the
U.S. remains low: real-world evidence from a National Laboratory Database. Diabetes Care,
44(9):2025-2032. DOI:10.2337/dc21-0723
Farxiga® (dapagliflozin) prescribing information (2023). AstraZeneca Pharmaceuticals LP.
Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/202293s020lbl.pdf
Invokana® (canagliflozin) prescribing information (2023). Janssen Pharmaceuticals, Inc.
Available at: https://www.janssenlabels.com/package-insert/product-monograph/prescribing-
information/INVOKANA-pi.pdf
Jardiance® (empagliflozin tablets) prescribing information (2023). Bayer HealthCare
Pharmaceuticals, Inc. Available at: https://content.boehringer-ingelheim.com/DAM/7d9c411c-
ec33-4f82-886f-af1e011f35bb/jardiance-us-pi.pdf
Kerendia® (finerenone tablets) prescribing information (2022). Boehringer Ingelheim
International GmbH. Available at:
https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/215341s000lbl.pdf
Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group (2012). KDIGO Clinical
Practice Guideline for anemia in chronic kidney disease. Kidney Int Suppl, 2(suppl):279-335.
Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group (2021). KDIGO
2021 clinical practice guideline for the management of blood pressure in chronic kidney disease.
Kidney Int, 99(3S):S1-S87. DOI:10.1016/j.kint.2020.11.003
Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group (2017). KDIGO
2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of
chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney Int Suppl, 7(1):1-59.
DOI:10.1016/j.kisu.2017.04.001
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group (2013). KDIGO 2012 clinical
practice guidelines for the evaluation and management of chronic kidney disease. Kidney Inter,
(suppl_3):1-150. DOI:10.1038/kisup.2012.76
Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group (2022). Kidney Int,
102(5S):S1-S127. DOI:10.1016/j.kint.2022.06.008
United States Renal Data System (2023). USRDS Annual Data Report: Epidemiology of kidney
disease in the United States. Available at: https://usrds-adr.niddk.nih.gov/2023/chronic-kidney-
disease
Wang V, Vilme H, Maciejewski ML & Boulware LE (2019). The economic burden of chronic kidney
disease and end-stage renal disease. Semin Nephrol, 36(4):319-330.
DOI:10.1016/j.semnephrol.2016.05.008