In an interview with Pharmacy Times, Ashish Verma, MBBS, assistant professor of nephrology at Boston University Chobanian & Avedisian School of Medicine, and Sophie Claudel, MD, a clinical instructor and resident physician in nephrology at Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, discussed their study on US chronic kidney disease (CKD) trends. While overall CKD prevalence has remained flat, the researchers found that CKD associated with diabetes is rising, even though diabetes prevalence itself has stayed stable. They attributed this to an aging population and improved survival among people with diabetes. Both experts emphasized that albuminuria is significantly underchecked compared with estimated glomerular filtration rate (eGFR), creating a major detection blind spot, particularly among patients with normal eGFR. With about 14% of the population estimated to have CKD, many remain undiagnosed. The researchers encouraged pharmacists to routinely ask at-risk patients whether their urine albumin has been tested.
Pharmacy Times: Why has overall chronic kidney disease (CKD) prevalence stayed flat despite new kidney-protective therapies reaching the market?
Ashish Verma, MBBS: Thank you, Luke. This is an excellent question pertaining to our study on trends in prevalence of CKD in the United States. The flat line is a balance of opposing forces here, and this is not a sign that nothing is changing. The key nuance is that when we look at the data, we found that overall CKD is stable over the years, but CKD with diabetes is actually increasing. Interestingly, diabetes prevalence itself is not increasing overall in the United States when you compare the earlier years with the 2021–2023 cycles. What that means is people with diabetes are living longer and accumulating kidney disease, because kidney disease is also a disease of an aging population. Also, in 2021, sodium-glucose cotransporter-2 (SGLT2) inhibitors got approved for diabetic kidney disease, and now even for non-diabetic kidney disease. But we need implementation of these therapies. Are these patients actually getting the therapies when they need them? Only then are you going to see a decline in CKD progression overall in the population. So the flat line is deceptive—a growing share of kidney disease is now tied to diabetes, even though diabetes prevalence is stable in the population.
Pharmacy Times: What does it mean for patient care that CKD is increasingly overlapping with heart disease and diabetes?
Key Takeaways
- Overall CKD prevalence in the U.S. has remained flat, but this stability conceals a rising share of CKD driven by diabetes, even as diabetes prevalence itself has held steady.
- Albuminuria (measured via UACR) is significantly underchecked compared with eGFR alone, causing many CKD cases—especially those with normal eGFR—to go undetected.
- Pharmacists can play a meaningful role in earlier CKD detection by routinely asking at-risk patients (those with diabetes, hypertension, or heart failure) whether their urine albumin has been tested and by supporting adherence to guideline-directed therapies.
Sophie Claude, MD: I think this is a great question, and it's actually a great opportunity for patients to get CKD care earlier on in the course of disease. We see a lot of CKD associated with diabetes, as Dr. Verma mentioned. We also commonly see CKD overlapping in patients with heart failure. The fact that these patients are touching the health care system, seeing other providers, and often being prescribed similar or the same medications that we would use to treat CKD is a great opportunity for earlier identification and earlier treatment of CKD.
Pharmacy Times: What should pharmacists watch for when counseling patients with diabetes who may be at risk for CKD?
Verma: Pharmacists actually play an important role here. In our data, we defined CKD as an eGFR less than 60, or a urine albumin-to-creatinine ratio (UACR) greater than 30. Usually, if you look at populations or clinics, people just check GFR and don't check albuminuria, and when you don't check albuminuria, you miss a lot of CKD—that's what we're showing in our data. Most of the CKD in our data among community-dwelling adults is actually driven by albuminuria. They have albuminuria and a normal GFR, but that's a blind spot, because you can still be at risk for cardiovascular disease and kidney disease progression. For pharmacists, I think it's very simple: they can ask patients who are at risk of CKD—those with diabetes, heart failure, or hypertension—”Have you had your urine albumin checked recently, or is your primary care checking it?" Moreover, even with therapies like SGLT2 inhibitors, finerenone (Kerendia; Bayer), and glucagon-like peptide-1 (GLP-1) receptor agonists, you need to monitor whether you're reducing albuminuria with these therapies to reduce future risk. I think pharmacists can play an important role just by asking a simple question: whether albuminuria was checked or not.
Pharmacy Times: How can pharmacists help support earlier detection of kidney disease in their patients?
Claudel: Dr. Verma was just highlighting this point: that albuminuria is very infrequently checked. We know this from epidemiologic data in patients at high risk for CKD, including those with diabetes and hypertension. Pharmacists who are seeing patients with these medical conditions that place them at high risk for CKD can take that extra step and ask, "Have you been screened for kidney disease, and if so, when was the last time?"—because it's not a one-time assessment. For many of these conditions, it needs to be repeated every year, or even more often, depending on how the patient is doing. Pharmacists, being in frequent communication with their patients and adjusting medications, have the opportunity to ask, "When was the last time we did this? Has your primary care done this?”—really keeping an eye on the evolving risk over time and helping to intervene that much earlier.
Pharmacy Times: What's the biggest takeaway from this data for frontline health care providers?
Verma: I would say the stable overall number hides a shifting reality. A growing share of CKD associated with diabetes and heart failure is alarming, and if you only check eGFR, you miss a lot of CKD. Those are the 2 most important points I would make.
Claudel: And to add to that, I think our finding that about 14% of the population has CKD is something that shouldn't be overlooked. That's a substantial proportion of our population, and many of those people are likely unaware that they have CKD. They may not know the strategies they can use in their own lives to reduce the risk of progression or how to talk to their providers about reducing the risk of progressive CKD and making sure they're on the right medications. Just highlighting that this is still a substantial population health problem in our country is a really important finding from our study.
Pharmacy Times: What's one action pharmacists can take today to help address these trends?
Verma: I would say, ask one question at the counter—”Have you had a urine albumin test this year?" If the patient has diabetes, high blood pressure, or heart disease, this is the most important question you should be asking at the counter.
Claudel: And once that question has been asked, or CKD has been identified, I think following up with, "Let's review your medications; let's make sure you're on those guideline-directed medications,” so that we can reduce the risk of this becoming a bigger problem. We have many treatments, but we know there is an implementation gap, and pharmacists can be key to filling that gap and making sure patients are getting on those medications. Hopefully, over time, we could start to see a downward trend in CKD prevalence here in the United States.
Pharmacy Times: Is there anything else that either of you would like to add?
Verma: I think the emphasis should be on albuminuria. We should be checking these high-risk patients for CKD with both eGFR and UACR, and this should be done by all primary care physicians. Pharmacists can also play a role by asking patients whether albuminuria was checked or not.
Claudel: I think educating patients as well on what this test means is important, because even if it's low but not normal, that doesn't mean it's a negative result. It does need to be followed and managed appropriately, and pharmacists can definitely play a key role here.
