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Hi, everybody. I'm Lee Perot. I am an endocrinologist and professor of medicine at the University of Colorado. Uh, today, we'll be talking about advancing kidney health and diabetes. And I just want to first point out that, um, I've moved my practice actually out of our main medical center, um, into a family medicine clinic associated with our university about 20 years ago, where I get to practice side by side with primary care and I get to see and admire all that they do. So, this is really for all of us. And these are the disclosures for myself. So this is our only learning objective, and that is to talk about implementing an evidence-based screening protocol for patients with type 2 diabetes and chronic kidney disease to ensure early detection and intervention. What we'll do is we'll start out with a case. And I kinda love this case because I feel like all of us have a patient like Sam. So Sam is a 58-year-old gentleman with type 2 diabetes for 13 years. Sometimes he takes his diabetes seriously and sometimes not, right? We've all heard this before. He does not know, have known complications of his diabetes, but he has not been seen in the past 2 years. His only complaint is pain in his feet. His current medications include metformin, sitagliptin, pioglitazone, hydrochlorothiazide, lisinopril, and simvastatin. His exam is unremarkable except for a BMI of 34, a BP of 145/92, an A1C of 8.5, an LDL of 95, and an EGFR of 55. And I just want everyone to take just a moment to kinda let those numbers and the final two bullet points sort of settle in. So take all that in and think to yourself how you would answer this next question. What would you tackle first? His BMI, BP, A1C, LDL, or EGFR. All of these things are not terrible, but they're not great. And I think the answer is you could probably tackle just about any of these first. So, this next figure comes from a consensus statement that was put forth by the American Diabetes Association in conjunction With the European Association for the Study of Diabetes and published in 2025. And really, the answer to the previous question probably centers around really asking Sam what he'd like to tackle first. So where we start is assessing key person characteristics, the individual's priorities. Maybe Sam is really not ready to kind of clean up his diet and become more active, but he is really concerned about his chronic kidney disease, because he's had chronic kidney disease in his family, and he seemed, see someone maybe put on dialysis, so he is really motivated by that. Let's think about his clinical characteristics and his motivation, his depression, his ability to do something about his health. So really asking Sam where he wants to start first might be the answer to that question. Then we would consider specific factors that impact choice of treatment. So really talking to Sam about his individualized glycemic and weight goals, and then selecting therapies, either, you know, pharmaceutical therapies or otherwise that would really have a positive impact on his weight, not lead to hypoglycemia, and prevent things like cardiovascular disease and kidney issues. So moving forward, and we would really educate Sam about what we're doing and why we're doing it and how we're trying to really meet his goals too. And once we come up with a shared decision making and a plan, we would implement that plan, agree on it, implement it, monitor it, and constantly review and agree on the plan, meaning that we really need to constantly reassess how that plan is meeting our goals and Sam's goals. And if we truly were to keep Sam in the center of this decision cycle, being that the goals of care were to prevent complications and optimize quality of life, there's one thing that has not been measured for Sam that is highly relevant to his care, and that is his urinary albumin to creatinine ratio. So how do you integrate UACR testing into routine diabetes care? Do you educate your patient about what it means and how you will use it? The result in their care. B, educate yourself about what it means and how you will use the result in patient care. C, educate your staff about what it means and how you will use the result in patient care. D, you could create order sets and customizations in the electronic medical record as a reminder, or E, all of the above. So think about how you would integrate UA or testing into routine diabetes care. OK, so what is the UACR and how do we use it? So, on this slide, you'll see the so-called heat map. It was developed by an international working group called KDGO, stands for Kidney Disease Improving Global Outcomes, and you'll see that they show the persistent albuminary categories on the top and the EGFR categories on the left-hand side here. And really, each of these adds specific information that is really multiplicative in terms of the patient's risk. So albuminuria, the way that I describe this to patient is that albuminuria or the UACR is really a measure of kidney damage. It is a very sensitive measure of kidney damage, and that usually precedes the decline in kidney function. The EGFR on the other hand, is a measure of kidney function. So if you think about the kidney as sort of a motor that cleans the blood, an EGFR of 100 can be sort of thought of as like 100% of that motor working. So in our particular patient, we know that his EGFR is 55. So if his UACR is below 30, maybe we'd be concerned about the low EGFR but we might be reassured by the low UACR. But, if the UAA starts to increase and climb and such that it's between 30 and 300, suddenly, we're a little bit more concerned. And if it's greater than 300 mg per gram, then we're extremely concerned, and extremely concerned for what? So, this heat map was developed to really predict the onset of end-stage renal disease. So the prediction of the decline in renal disease. But the truth is that people with kidney disease typically do not die from kidney disease. They actually die from cardiovascular disease. So the heat map has been applied to other conditions. This is in a very busy slide, so I'll make it very simple for everybody. There's the age less than 65 shown on the left, age greater than 65 shown on the right. And the point being is that heat map looks really, really similar for the progression of kidney disease as it does for other things, specifically the things that are now included in stars here, all cause mortality, myocardial infarction, cardiovascular mortality, stroke, heart failure, atrial fibrillation. And hospitalization and peripheral arterial disease. So it's important as we have that conversation with Sam to really explain why we're measuring the UACR and how we'll use it in terms of stratifying his risk for not only the progression of kidney disease, but the onset and progression of cardiovascular disease. So how does the risk level determine the frequency of monitoring? So indeed that progression of the UACR, it not only determines how concerned we are, but how often we actually measure it. So again, here we are with Sam, his, his EGFR being 55. And so if that UACR comes out to be less than 30, we might check it once a year. So that's the one. If it's between 30 and 300, we would probably check it twice a year. And if it was greater than 300, check. it 3 times per year. So that word treat, what does that mean? It really means that we're treating all of the risk factors that are leading to that increase in UACR and the decline in EGFR, meaning we treat the A, B, C's of diabetes, A1C, BP, and cholesterol. So, how exactly do we treat the ABC's of diabetes? Well, This is a great figure. I really, really love it, showing this sort of pyramid in terms of the progression of care. So what we're showing on the bottom are things like diet, exercise, smoking cessation, and weight. These things are foundational. And it says below these things for diabetes and CKD, but I'd argue for everybody, for anything that's going on with anybody. These are where we start in terms of managing patients with type 2 diabetes and chronic kidney disease. As we move up the pyramid, you're looking at first-line drug therapies. Metformin typically remains first-line drug therapy, but SGLT-2 inhibitors have really come into the fold. And I would argue that the use of an SGLT-2 inhibitor. In a patient with type 2 diabetes and CKD, you should use it independent of the person's A1C. So this means even if the person's A1C is 5.9%, you would still want to use this to prevent the progression of kidney disease. Now,