Speaker 1: Pushkin, this is solvable. I'm Ronald Young Jr. If you're
Speaker 1: anything like me, As you get older, you begin to
Speaker 1: think about your general health and wellness, being more active,
Speaker 1: my blood pressure, my cholesterol, trying to eat more vegetables,
Speaker 1: making the appointment for my annual physical. But even if
Speaker 1: I take the time to tend to my lifestyle choices
Speaker 1: and overall health, some preventative care measures may still slip
Speaker 1: through the cracks, just because I don't know all the
Speaker 1: questions to ask. Patients are going into their doctor asking
Speaker 1: to get their cholesterol checked. I mean, how many people
Speaker 1: do you know they're going to their doctor and say,
Speaker 1: can I have my kidney's checked? I certainly don't think
Speaker 1: about my kidneys on a regular basis, But one in
Speaker 1: seven adults has chronic kidney disease or CKD, and because
Speaker 1: it's asymptomatic in the early stages, nine people with the
Speaker 1: disease have no idea they've got it. And today we're
Speaker 1: phased with the situation where a wonderful policy has created
Speaker 1: an incentive where we put a lot of resources in
Speaker 1: the end stage of a disease and nothing on prevention
Speaker 1: for end stage renal disease. Also known as kidney failure.
Speaker 1: Patients are often treated with dialysis. It's a very time
Speaker 1: consuming and exhaustive treatment that can save lives, but can
Speaker 1: also be extremely disruptive. Doctor Carmen Peralta co founded the
Speaker 1: Kidney Health Research Collaborative at the University of California, San
Speaker 1: Francisco to change all that. Some of the first obstacles
Speaker 1: were information really understanding the epidemiology of disease, what populations
Speaker 1: are affected, what are the risk factors for disease, why
Speaker 1: it happens. Doctor Peralta is also the chief medical officer
Speaker 1: at Cricket Health, a for profit company that specializes in
Speaker 1: helping people with kidney disease by supporting early detection programs
Speaker 1: and providing risk assessments. A big, important, gigantic reason to
Speaker 1: detect the disease early. The earlier you detected, the more
Speaker 1: chances you have to prevent it from progressing. Nearly thirty
Speaker 1: seven million Americans lived with chronic kidney disease. Getting an
Speaker 1: early diagnosis could improve the quality of life for many
Speaker 1: and even prevent the necessity of in stage treatment. Chronic
Speaker 1: kidney disease is solvable. How did you get interested in
Speaker 1: kidneys specifically, my grandfather, who I never met, was a physician,
Speaker 1: and so I grew up in em Barranquia, Colombia, and
Speaker 1: he was one of those physicians that would just do
Speaker 1: anything for his patience. And my mother always talked about
Speaker 1: him and the way people loved him and all the
Speaker 1: things that he did, and so that was an inspiration.
Speaker 1: My uncle was also a doctor, and I love the
Speaker 1: physiology of the kidney. I mean, when you probably talk
Speaker 1: to people about kidneys, they think, oh, they filter your blood,
Speaker 1: which is true, but the kidney has a ton of
Speaker 1: other functions, regulating the water content in your body, blood pressure,
Speaker 1: helping make red blood cells, and all these things that
Speaker 1: I found it to be absolutely fascinating. And I was
Speaker 1: struck by several things that happened during my training. One
Speaker 1: was meeting patients that would arrive in an emergency room
Speaker 1: just sort of saying that they didn't feel well or
Speaker 1: maybe they were swollen, or they were having trouble breathing,
Speaker 1: and then they were diagnosed with kidney failure what we
Speaker 1: call end stage renal disease or end stage kidney disease,
Speaker 1: and told that they needed dialysis. I also was struck
Speaker 1: by the reports that we were having in those times.
Speaker 1: And remember this is the early nineteen nineties, thinking about
Speaker 1: the race disparities and SoC economic disparities that we saw
Speaker 1: in the disease, and that truly marked me because I
Speaker 1: was thinking, why is this disease devastating this community is
Speaker 1: in this way, and why are people showing up at
Speaker 1: the very end stage of a disease? How is the
Speaker 1: treatment for kidney disease changed over the years? Has the
Speaker 1: medical establishment shifted the way it responds to the disease
Speaker 1: as the number of cases in the US has grown
Speaker 1: a lot of people don't know this. So in nineteen
Speaker 1: sixty five, we had the Medicare Medicaid Act right that
Speaker 1: now allowed us to provide care for seniors or in
Speaker 1: persons with disabilities or low income right. And one of
Speaker 1: the things people don't realize is that in nineteen seventy
Speaker 1: two there was an amendment that was done to the
Speaker 1: Medicare where people with end stage kidney failure would qualify
Speaker 1: for services through Medicare regardless of age. And the reason
Speaker 1: is because right around in the sixties and late sixties,
Speaker 1: the technology both for the dialysis machine and what we
Speaker 1: call vascular access, which means the way that we can
Speaker 1: access the blood to clean it had improved in a
Speaker 1: way that allowed people to get dialysis in a chronic fashion.
Speaker 1: So it became a life saving treatment, but it was
Speaker 1: really expensed and only very very few people could actually
Speaker 1: get the treatment, and in order to reduce those disparities
Speaker 1: and make it available to every American, there was a
Speaker 1: decision to cover the service. But at the time, the
Speaker 1: projections were that maybe there would be a you know,
Speaker 1: maybe twenty thirty thousand people on dialysis, you know, maybe
Speaker 1: would cost a billion dollars or something of the sort.
Speaker 1: And today we're faced with a situation where a wonderful
Speaker 1: policy has created an incentive where we put a lot
Speaker 1: of resources in the end stage of a disease and
Speaker 1: nothing on prevention. We couldn't have anticipated that. Now we
Speaker 1: have over half a million persons undergoing dialysis treatment in
Speaker 1: the US, and so it's incredibly expensive, causes a lot
Speaker 1: of suffering, and naively, you know, as a trainee and
Speaker 1: thinking that that I could solve it, I thought it's
Speaker 1: so easy. All we need to do is test people
Speaker 1: who have respectors for the kidney disease, detect the disease early,
Speaker 1: so we can manage it early, educate people on physicians,
Speaker 1: put in all the management strategies, and then this won't happen.
Speaker 1: I thought, this is solvable because what we need is
Speaker 1: to invest in the early stages. Little did I know
Speaker 1: then that there were so many questions to be answered.
Speaker 1: Can you give me some examples, meaning what test should
Speaker 1: we order, who should we test, what populations? Understanding why
Speaker 1: the race hathing differences that we see in outcomes where
Speaker 1: people who self identifies African Americans have under order of
Speaker 1: two point seven times more likely to start dialysis than
Speaker 1: compare the white persons, for example, Hispanics about one point
Speaker 1: three times. So I was very curious to understand those
Speaker 1: because if you don't know the causes of those things,
Speaker 1: that you can't solve them. So what happens at Cricket Health?
Speaker 1: How do you address these problems? So at Cricket Health,
Speaker 1: we partner with payers and health systems to care for
Speaker 1: people with kidney disease. We then use laboratory data or
Speaker 1: algorithms to identify persons who might be at risk for
Speaker 1: having kidney disease or who we know have kidney disease.
Speaker 1: So we provide a multiary care team that includes nurse,
Speaker 1: social worker, dietitian, pharmacist, care navigator, and a peer mentor
Speaker 1: because it is another patient that has gone through the
Speaker 1: journey of kidney disease that I cannot concially help someone
Speaker 1: that's just starting. And then what we do is we
Speaker 1: essentially number one, put in evidence based measures to slow
Speaker 1: the progression of disease for those who we can't despite
Speaker 1: the best of our abilities, we prepare them and give
Speaker 1: them a lot of education around both kidneys, how to
Speaker 1: keep the kidney healthy, but also what potential therapies they
Speaker 1: could use to treat their kidney disease, whether it's a transplantation, dialysis,
Speaker 1: or medical management without dialysis. We then work with the
Speaker 1: patient doctors and we are the eyes andeers in between
Speaker 1: appointments for the providers. They don't have the time to
Speaker 1: see people as often as they need care, and so
Speaker 1: we are the service that is there to be able
Speaker 1: to give this entire support through the kidney journey. You're
Speaker 1: saying that we are being more reactive than proactive, and
Speaker 1: yours to do early testing are more proactive efforts. What
Speaker 1: happens after catching it early. We're not putting people on
Speaker 1: dialysis necessarily early, but I'm assuming that there are treatments
Speaker 1: for people who do detect chronic kidney disease as early
Speaker 1: as possible. Absolutely. One thing to know is that typically
Speaker 1: kidney disease doesn't really have a lot of symptoms until
Speaker 1: it's very advanced. And also the symptoms tend to be
Speaker 1: not very specific, meaning it's just maybe tired, maybe a
Speaker 1: little bit of swollen legs, or difficulty breathing. The only
Speaker 1: way to know that something might be going on with
Speaker 1: the kidneys is to test the blood or the urine
Speaker 1: in the United States, as high blood pressure and diabetes
Speaker 1: are the typical factors that are associated with kidney disease,
Speaker 1: and so the mainstay of the treatment is controlling the
Speaker 1: typical risk factors. They lose weight, stop smoking, the typical
Speaker 1: things to keep health. In addition, there are certain medications
Speaker 1: that are crucially important to consider impatience with kidney disease.
Speaker 1: Classes of medications that have been on the market for
Speaker 1: decades called ACE inhibitor or JE tensing converting hiber flock
Speaker 1: so as or ARBs. Those are the pills that people
Speaker 1: might recognize that are also used for blood pressure treatment.
Speaker 1: So those have shown to potentially reduce the progression of
Speaker 1: kidney disease and reduce some of the complications. The other
Speaker 1: thing that we have to think about is even as
Speaker 1: people are progressing, and let's say that, Okay, no matter
Speaker 1: what you do, we do everything perfectly, you know, do
Speaker 1: you take every right pill, you do all the right treatments,
Speaker 1: everything is perfect, But some people will progress. And the
Speaker 1: truth is that sometimes we don't know why despite our
Speaker 1: best treatments. Still the best treatments for kidney failures that transplant,
Speaker 1: and so a big, important, gigantic reason to detect the
Speaker 1: disease early. The earlier you detect it, the more chances
Speaker 1: you have to prevent it from progressing. But also it
Speaker 1: gives an opportunity for you to actually be in control
Speaker 1: and have the possibility of having a transplant before you
Speaker 1: even need dialysis. So that's another reason rather than waiting
Speaker 1: until somebody needs dialysis. When you're trying to do preventative care,
Speaker 1: trying to do early detection, what types of obstacles do
Speaker 1: you run into when you're trying to implement those plans.
Speaker 1: Some of the first obstacles were information really understanding the
Speaker 1: epidemiology of disease. What populations are affected, what are the
Speaker 1: risk factors for disease, why it happens. There's also a
Speaker 1: lot of research going on really around just how can
Speaker 1: a disease happens, like at the tissue level, of the
Speaker 1: molecular level, at the mechanistic level of really understanding that
Speaker 1: in order to develop new targets. Then the next implementation,
Speaker 1: which I worked on, is to say, Okay, now we
Speaker 1: need to educate the patient about kidney health, and we
Speaker 1: also need to educate primary providers. And when you think
Speaker 1: about it, in the United States, primary care providers are
Speaker 1: very busy, and they have to deal with many things,
Speaker 1: you know, and sometimes they have list that is so
Speaker 1: long of the things that they have to address for
Speaker 1: our patient. The patienter might have a different list. A
Speaker 1: primarycare provider might say, oh, we're going to talk about
Speaker 1: your blood person and your diabetes, but the patient wants
Speaker 1: to talk about their headache. Now you're adding another disease
Speaker 1: that they have to worry about. So a big part
Speaker 1: of it has been how do we then provide tools
Speaker 1: so that we can help the primary care provider be
Speaker 1: efficient and actually understand how to test for kidney disease
Speaker 1: flag When a patient has kidney disease. So we did
Speaker 1: a couple of projects where we did that, where we
Speaker 1: actually tested some tools to improve recognition of kidney disease
Speaker 1: early with the hope that the end the management would improve.
Speaker 1: How do you recomcile the work that you're doing being
Speaker 1: very specific about kidneys, but also probably being something that
Speaker 1: could be applied universally when it comes to healthcare. Do
Speaker 1: you ever struggle with kind of the existential nature of saying, like, hey,
Speaker 1: you know, I'll try to fix the kidneys, but this
Speaker 1: is probably something that needs to be applied probably in
Speaker 1: our hearts, probably you know, all kinds of other transplants
Speaker 1: as well, when we're talking about prevention versus of reactive treatment.
Speaker 1: Oh yeah, Well, but I can tell you is I
Speaker 1: would love to just change the world right for everybody.
Speaker 1: I think the thing that grabs me about kidney disease
Speaker 1: is that it is so stark how much we invest
Speaker 1: at the end of the disease compared to others. Now,
Speaker 1: I'm not saying there's not a lot that we need
Speaker 1: to do in diabetes and heart disease and high cholesterol
Speaker 1: and all of these kinds of things, But when you
Speaker 1: think about it, let's say, for example, heart disease. There's
Speaker 1: a lot more knowledge out there, and primary care providers
Speaker 1: are more aware. Patients are going into their doctor asking
Speaker 1: to get their cholesterol checked. I mean, how many people
Speaker 1: do you know they're going to their doctor and say,
Speaker 1: can I have my kidneys checked? Right? And so I
Speaker 1: think we've done a little bit better in the healthcare
Speaker 1: system to talk about prevention when it comes to kidney health.
Speaker 1: There's actually an executive order that was signed a couple
Speaker 1: of years ago under the Trump administration, and in fact,
Speaker 1: they are testing specifically models that promote early detection of
Speaker 1: disease management early because they're realizing that the cost of
Speaker 1: just putting all the efforts at the end of the
Speaker 1: disease costs a lot of money and cause a lot
Speaker 1: of suffering. So we are seeing a little bit of
Speaker 1: a move. What I hope is that when we move
Speaker 1: to paying for value and good outcomes, is that this
Speaker 1: actually does that for all chronic diseases. And I think
Speaker 1: we're seeing some of that shift in other chronic diseases
Speaker 1: as well. It's testing expensive, Nope, it's actually quite cheap.
Speaker 1: So if you just do you know, the blood and
Speaker 1: the urine test can be pretty cheap. Why wouldn't this
Speaker 1: just be a posture The doctors more widely take to say, hey,
Speaker 1: why don't we just test this to make sure you're good? Yeah? Yeah,
Speaker 1: So the funny thing is that the blood test is
Speaker 1: often included in the physical but typically the urins not tested.
Speaker 1: It's just a blood and you need really both tests.
Speaker 1: I think it's a couple of things. One is lack
Speaker 1: of education, both for patients and providers. I think it's
Speaker 1: inaccurate perception by providers that if you find kidney disease
Speaker 1: or a leader, that there's nothing to do. And I
Speaker 1: think I've already hopefully convinced people that there is a
Speaker 1: lot to do. And number three again is just not
Speaker 1: having the time, you right to deal with so many
Speaker 1: of the issues that our prima care providers have to
Speaker 1: deal with, and frankly like a lack of support. You know,
Speaker 1: the job of US special is actually to support the
Speaker 1: Prima care community in handling all the competing, you know,
Speaker 1: diseases that they have to they have to handle. Doctor praulta,
Speaker 1: is there a way in which we perpetuate the brokenness
Speaker 1: of the American healthcare system? And when I say that
Speaker 1: I guess I'm asking in whose interest is it to
Speaker 1: work from the reactive stance rather than the proactive stance. Well,
Speaker 1: I think if you think about it, the healthcare system
Speaker 1: in America rewards for procedures, for visits, for volume. So
Speaker 1: the more patients to see, the more procedures that you do,
Speaker 1: the more money a system will make. Right, And that
Speaker 1: is what we call quote unquote fee for service, which
Speaker 1: means that you get paid a fee for a service
Speaker 1: that you do. But we are seeing a transformation into
Speaker 1: what we call value based care, which is actually let's
Speaker 1: pay for keeping people healthy, for keeping people out of
Speaker 1: the hospital. And let's say five to ten years. What
Speaker 1: does this look like or do you have a timeline
Speaker 1: for when you say, hey, you know what we've done,
Speaker 1: it solved, We're good. Yeah. Well I'm ready to change
Speaker 1: the world today. Right. So I wish I could tell
Speaker 1: you that in five years from now, we have touched
Speaker 1: hundreds of thousands of lives and that barely any of
Speaker 1: these people on dialysis, that the majority of our at home,
Speaker 1: the majority have gotten a transplant, and that people are
Speaker 1: living a full life even with kidney disease. So I
Speaker 1: am still part of UCSF in a smaller capacity, but
Speaker 1: being the chief medical officer Cricket has really allowed me
Speaker 1: to take everything from my clinical experience, from what I know,
Speaker 1: from what we know about the disease, and implemented and
Speaker 1: actually make it a viable and incredibly successful program that
Speaker 1: we are implementing nationwide. I said to me, this is
Speaker 1: an accelerator and the final part is again a value
Speaker 1: based program where we are rewarded for keeping people healthy.
Speaker 1: Do you guys take insurance, Yeah, we work with insurance companies,
Speaker 1: health systems and so forth. Yet do you ever have
Speaker 1: concerned that being a part of a for profit company
Speaker 1: with albeit an altruistic mission, that you'll ever be beholden
Speaker 1: to the bottom line, to stakeholders, to the shareholders, to
Speaker 1: the folks that really need the business to make money,
Speaker 1: even if that runs a skew of the mission. I mean,
Speaker 1: there's always going to be, you know, a business that
Speaker 1: you're building. But the one thing about Cricket Health that
Speaker 1: makes me very product that we are changing the way
Speaker 1: even that reimbursement happens. So pretty much everything that we
Speaker 1: are doing is value based. Once you change the incentive,
Speaker 1: then it's a whole different way that you're thinking about
Speaker 1: how you're going to build your business, and so that's
Speaker 1: really what we're trying to do. What can listeners do
Speaker 1: if they're interested in learning more about chronic kidney disease
Speaker 1: or even the research that you're doing, or if they
Speaker 1: want to get involved, What can listeners do? First of all,
Speaker 1: get informed. The CDC has an incredible website that talks
Speaker 1: about kidney disease. I would say, you know, talk to
Speaker 1: your family members and community, because when you talk about it,
Speaker 1: you'll discover that there's more people you know that have
Speaker 1: kidneys than you ever imagined. You know. The other thing
Speaker 1: is talk to your doctor, talk and say, okay, should
Speaker 1: I be tested? And then what would we do about it?
Speaker 1: I think that's important. I think people should also if
Speaker 1: they have loved ones who are affected with kiddings, he
Speaker 1: should learn about transplantation and living donation, for example. But
Speaker 1: I certainly urged people to go get informed. Doctor Parlta,
Speaker 1: thank you so much for being with us today. Oh
Speaker 1: it's been so fun to talk to you. And I
Speaker 1: tell you that we must have hope and when we
Speaker 1: think about our healthcare system, understand that compassion is a
Speaker 1: big part of what we need. To build. Doctor Carmen
Speaker 1: Parlta is the chief medical Officer at Cricket Health. She
Speaker 1: co founded the Kidney Health Research Collaborative at University of California,
Speaker 1: San Francisco and the San Francisco VA. If you'd like
Speaker 1: to learn more about kidney health and preventative medicine, we'll
Speaker 1: include a link to the CDC page Doctor Barlta recommended
Speaker 1: in our show notes. Solvable is produced by Jocelyn Frank,
Speaker 1: research by David Jack, booking by Lisa Dunn, editing help
Speaker 1: from Keyshell Williams. Our managing producer is Sasha Matthias. Our
Speaker 1: executive producer is Mio LaBelle. I'm Ronald Young Junior. Thanks
Speaker 1: for listening.