ASN's first-ever kidney health guidance provides nephrologists and all other members of the kidney care team with advice on the best practices for holistic, nonstigmatizing care for obesity that incorporates lifestyle, psychosocial interventions, bariatric surgery, and a mounting arsenal of medications (1).
ASN decided to begin creating kidney health guidance to help speed the implementation of the growing array of treatments available for patients with kidney diseases, explained Holly J. Kramer, MD, MPH, professor in the Division of Nephrology at Loyola University Chicago's Stritch School of Medicine, IL. “We wanted to improve the treatment of kidney diseases by guiding nephrologists on the use of newer therapies,” Kramer said.
Kramer, who cochaired the Kidney Health Guidance Workgroup that drafted the guidance on obesity care, explained that clinical guidance differs from a clinical practice guideline. Experts draft clinical practice guidelines based on a systematic literature review and weigh recommendations based on the evidence. These formal documents can take years to complete and publish and are typically updated on a regular 5- to 10-year schedule. Experts can more quickly draft guidance documents as practical guides for clinicians and can respond more rapidly to developments in evidence.
Many fields, including specialties like cardiology, oncology, and pulmonology, use clinical guidance documents to supplement more formal clinical guidelines, noted T. Alp Ikizler, MD, FASN, director of the Division of Nephrology and Hypertension at Vanderbilt University Medical Center, Nashville, TN, and cochair of the workgroup. However, Ikizler said that such documents have not been common in nephrology. ASN saw an opportunity to provide additional day-to-day, accessible clinical guidance for the entire team of clinicians treating patients with kidney diseases. “These are going to be living documents,” Ikizler said. “There will be updates as the science and information grows within the field.”
ASN selected obesity management as the topic for the first health guidance. Approximately 42% of US adults are classified as having obesity, a proportion that has grown by more than 10% over the past 2 decades (1). The condition can contribute to the development of kidney diseases, worsen a patient's prognosis, and exacerbate comorbidities, Ikizler explained. It has historically been difficult to manage, but he noted that a growing number of tried and true, as well as new, interventions are available to treat the condition.
“Clinicians are having their patients come to them with questions about what the best [weight loss] approach would be for them, whether it's medical therapy, behavioral therapy, [or] lifestyle modifications,” said ASN President Deidra C. Crews, MD, ScM, FASN. “That made us think this was a great topic [on which] to begin our Kidney Health Guidance.”
Empathetic care
The ASN Kidney Health Guidance on the Management of Obesity in Persons Living with Kidney Diseases emphasizes the importance of discussing weight loss with patients in an empathetic and nonstigmatizing manner. “The first thing would be asking the patient if they feel comfortable discussing weight,” Kramer said. “Some people feel uncomfortable discussing their weight, so you have to be really careful about how you discuss it with the patient.”
Some tips include avoiding stigmatizing language, such as describing someone as fat or obese, and using the term unhealthy weight instead. Kramer suggested discussing the potential of weight loss to help patients achieve their kidney care goals. For example, she explained that the goal may be losing weight to prevent progression, improve quality of life, or help meet transplant eligibility requirements.
The guidance also emphasizes the importance of addressing the patient's mental health. Patients with obesity and kidney diseases may feel shame or blame related to their conditions. Patients may also have mental health conditions like anxiety, depression, substance use disorders, eating disorders, or other mental health conditions that may make weight management difficult, Kramer explained. “If you don't get in there and figure out the psychological components that are driving the difficulties in managing weight and lifestyle, you are not going to get very far,” she explained.
The guidance recommends lifestyle changes, such as dietary patterns, creating an exercise schedule suitable for the patient's circumstances and their comorbidities, and getting adequate sleep, as the foundational steps for patients interested in weight loss. “You need to give the lifestyle a chance to work,” she encouraged. It also acknowledges that social determinants of health, such as food or housing insecurity, economic status, health literacy, and access to transportation, may all impede treatment for obesity and kidney diseases. These complexities must be addressed in the treatment plan.
Many patients will not experience sustained weight loss from lifestyle changes; for these patients, the guidance recommends considering medications as part of the treatment plan. The guidance highlights glucagon-like peptide-1 (GLP-1) receptor agonists based on evidence that they can slow chronic kidney disease progression, prevent heart failure, and improve patient quality of life and functioning. The guidance also details other medications commonly used for weight loss that may be appropriate and explains what nephrologists need to consider about their use in patients with kidney diseases.
“There's been a lot of excitement about the studies that have come out showing the benefits of these medications in terms of their ability to help people to lose weight but also how they can actually lead to slower progression of kidney disease as well as reductions in cardiovascular outcomes,” Crews stated. “There's still a number a number of challenges around making sure that they’re getting to everyone who might benefit from them.”
She explained that many patients have struggled to get such medications at an affordable cost, indicating a need for more advocacy. Additionally, some clinicians have been hesitant to prescribe them.
“Most nephrologists may not feel comfortable prescribing antiobesity medications,” Kramer acknowledged. “We need to do more to educate nephrologists on how to safely utilize these medications across the entire spectrum of kidney disease stages.”
For example, Kramer explained that for patients with more advanced kidney diseases, nephrologists must more slowly and cautiously escalate doses of weight-loss medications and carefully monitor for side effects, which may be more common in patients with worse kidney function. “Some people just don't tolerate higher doses,” she said. “You’ve got to go slow. People can get nauseous or ill from the medication.”
Ikizler noted how essential it is to recognize that these medications, as well as more invasive approaches like metabolic or bariatric surgery, can be effective in patients with kidney diseases. However, nephrologists need to follow up closely. “We need to be very diligent and provide oversight,” he said. “We cannot just sort of prescribe and forget.”
As noted in the guidance, kidney diseases should not be considered a contraindication for metabolic and bariatric surgery. Patients with advanced kidney diseases or who require dialysis may have higher rates of complications or death after surgery than those with earlier stages of kidney diseases. Still, overall rates of mortality in patients with kidney diseases are low. It also highlights factors that may make some patients poor candidates for bariatric surgery, such as substance use disorders or eating disorders.
In addition to providing practical advice for nephrologists on all of these issues, the guidance also notes that there are likely unappreciated benefits of these interventions for patients with kidney diseases beyond just weight loss. Ikizler said he sees a role for nephrologists in helping the kidney care team and patients understand them. “It may have multiple different impacts [on kidney health], and we need to figure those out,” he said. “Just losing weight should not be our primary or only target. We should also look at other metabolic benefits that come from these [therapies].”
Team-based approach
Kramer acknowledged that nephrologists may have limited time for patient consultations and limited training in obesity care, lifestyle modifications, or mental health. “We know that nephrologists have a lot to do,” Ikizler said. “We are very thorough and very involved in our patients’ care. [Obesity management] will bring an additional [commitment]. The way to manage that is to delegate or refer certain responsibilities and tasks to other health care team members.”
The guidance emphasizes the benefits of collaborating with primary care physicians, advanced practice professionals, nurse educators, dieticians, mental health clinicians, mobility and physical activity experts, and others to provide holistic care for obesity. “It's going to take a team approach to help these patients not only get the weight off but keep it off,” Kramer said.
Some clinics already hire nurse educators to work with patients with kidney diseases, and they can help patients understand the influence of weight on kidney health, Kramer noted. However, most public and private payers do not currently cover these services. Medicare and private insurance typically pay for medical nutrition therapy for up to 3 years. Still, Kramer said that only 1 in 10 patients with kidney diseases ever meets with a registered dietician.
Ikizler noted that nurses can play a pivotal role in patient follow-up and medication management. He noted that social workers can also help address socioeconomic challenges and psychosocial concerns and help patients with medication access, affordability, and medication adherence.
Kramer also opined that new care models are needed. For example, cardiologists routinely suggest that patients undergo physical rehabilitation after a heart attack, for which they get training and guidance on how to exercise. However, patients with kidney diseases do not typically receive this kind of support. “That is a huge gap in care because exercise is good not only for the physical functioning of the body but also for mental health,” she said.
The guidance also attempts to define the nephrologist's role in using these new classes of medications and when they might need to collaborate with other specialties. Ikizler noted that several specialties, including endocrinology, cardiology, and general and internal medicine, also prescribe weight-loss medications. “It is important we talk with them all the time,” he said. “We need to communicate [medication decisions] and sometimes allow others to prescribe these medications but also provide some oversight from the kidney perspective.”
Advocating for access
Kramer acknowledged that some of the recommendations are aspirational and that some interventions may not be available in every practice context or accessible to every patient. “Not everyone will have access to all of these therapies,” she explained. “It depends on your practice.” For example, some practices may not have dieticians with expertise in kidney diseases and obesity or clinicians who can help patients overcome physical barriers to exercise. Access to bariatric surgery may also be limited because few centers accept patients who are considered high risk or those who lack insurance coverage. Patients from rural areas may also have limited access to mental health and other types of specialty care. Out-of-pocket costs are also a major barrier to many patients accessing newer weight-loss therapies like GLP-1 receptor agonists and gastric inhibitory polypeptide receptor agonists.
The guidance also lays out the need for policy solutions to address some of these patient access and systemic problems. Ikizler noted that many professional societies, like the American Cancer Society, have successfully leveraged the expert consensus in their clinical guidance documents to help push for policy change. “We felt we had to set the bar high,” Ikizler said. “Having these guidance documents is critical to making policy changes.”
Kramer notes that through recent government price negotiations, sodium-glucose cotransporter-2 inhibitors will soon be available to Medicare patients at reduced costs. She hopes that policymakers will include GLP-1 agonists in future price negotiations. In the meantime, nephrologists can advocate for coverage and reduced costs for patients covered by Medicaid or private insurance. She argued that there is a strong cost-benefit argument for coverage, which may help keep someone from needing dialysis or may allow them to undergo transplant.
Ikizler highlighted the importance of advocating for policy changes that increase access to weight-loss medications and that prioritize access for patients with kidney diseases who are at high risk of complications. He also said that policies supporting patient access to multidisciplinary care teams—including nurses, social workers, mental health clinicians, dieticians, and other specialties—are also needed. “Policies should allow us to create a health care team that manages our patients,” he said. “Obesity management is just one component of kidney care that requires a team effort.”
In the meantime, Kramer emphasized that the most critical advice for nephrologists consulting the guidance is to start by talking with their patients about weight in a supportive way. “Ask your patient if they want to discuss their weight,” she suggested. “If you ask them in an empathetic way, in a nonthreatening way, I bet the majority of people would say, ‘Yes, I want to talk about it.’ We really need to talk about it.”
Reference
Ikizler TA, et al. ASN Kidney Health Guidance on the Management of Obesity in Persons Living with Kidney Diseases. J Am Soc Nephrol (published online September 18, 2024). doi: 10.1681/ASN.0000000512
