many of them have low-ish K anyway because of their hyperaldo

even in their 2024 guidelines they downgrade the level of evidence for resistant hypertension.
Yes, spiro causes hyperK but that is easily managed with diuretics, especially in CKD.

- Just use BB - everyone has an indication anyway (except they don’t work as well as spiro)
- use wildly expensive and not marketed aprocitentan
- Renal denervation

No COI mentioned, although previously heavily involved with Medtronic
2/2
@hswapnil.medsky.social
@jordybc.bsky.social

7. Personal level. Beyond his talent and expertise, I met an extraordinary man. Humble, altruistic, wise, friendly, and with a great sense of humor. I brought him a vacuolar cast tie as a present and he wore it proudly right away 🤩

we can get it if needed for transplant by referring to local endocrinologists

I’m particularly enthusiastic about the weight loss (which is not scientifically controversial), since this makes a big difference for transplant eligibility. The previous advice of exercise and diet just isn’t realistic in ESKD and so many just end up on dialysis for life…

Turns out the effect size it similar in other trials that are probably just underpowered
journals.lww.com/cjasn/abstra...

jamanetwork.com/journals/jam...

#NephSky

I think everyone is rightly sceptical if the large effect size, but given the high risk CVD risk and low cost/risk with fish oil, I feel it is too reactionary to just say “we need more trials”. We always need more trials, but they’re not likely to be forthcoming any time soon.
#NephSky

Slightly unrelated, but that’s pretty poor blood pressure control for a high risk T1D population, both for CVD and kidney endpoints 😬 #KidneyWk#

I like the idea of personalised treatment of DKD in theory, but when all 4 pillars have CVD benefits independent of each other, I find it hard to argue that patients shouldn’t be on all drugs at once.
But ideally, yes, different drugs for different phenotypes.

if we get to a point where everyone with DKD is on RAASi, SGLT2i, nsMRA, GLP1-RA and BP control, then maybe the added benefit of further treatment doesn’t add enough benefit compared to the added cost?
As you said, it will be near impossible to prove it…

Agree, diminishing returns with improvements in SoC.

also, some clinical nephrologists won’t accept an albuminuria outcome regardless of strong data, so hard endpoints would be better to increase treatment uptake.
It’s hard enough as it is to get nephrologists to prescribe finerenone… 😜🤓

I’m okay with albuminuria for DKD because the data is so strong and it’s not a waxing and waning disease.
For other diseases, eg. GN which can achieve complete remission and then relapse, I feel it’s necessary with different endpoints than just proteinuria.

fair enough as interim results, but would like to eGFR slope.
The days of hard kidney endpoints may be over, but maybe that’s okay given the strong evidence in support of eGFR slope or albuminuria as surrogates

Great piece, nonetheless. Glad to hear you are doing well 😃