Diabetes and kidney disease: the link to cardiovascular disease

In this episode of the Healthy Heart Trust podcast, we explored the complex interplay between diabetes, kidney disease, and cardiovascular health. The discussion examined how diabetes disrupts glucose, lipid, and protein metabolism, and how these disturbances contribute to vascular, cardiac, and renal complications. We highlighted the importance of early diagnosis and preventative strategies, particularly in high‑risk populations. 

The episode also addressed the close relationship between chronic kidney disease and cardiovascular risk, underscoring the value of integrated care through combined clinics. In addition, we discussed ongoing research into novel therapeutic targets for diabetic kidney disease, including emerging treatments such as SGLT2 inhibitors, GLP‑1 receptor agonists, and finerenone. Overall, the key message emphasised the vital role of early intervention in reducing long‑term health consequences.

Transcript

SPEAKER_01 0:13

Hello and welcome to episode four of the Healthy Heart Trust Podcast. My name is Albert Ferrow. I'm the chair of the Healthy Heart Trust. And I'm delighted to be joined today by two uh eminent experts, one in the field of diabetes and the other in the field of kidney disease. Diabetes is Professor Luigi Nudi, and uh kidney disease is Professor David Goldsmith. Uh David is actually one of our trustees as well. Uh and Luigi is a uh colleague of mine. So welcome to both of you. Thank you.

SPEAKER_00 0:46

Thank you, Albert.

SPEAKER_01 0:48

So maybe we'll start um Luigi with you. Um, and maybe talk a little bit about diabetes. Um, and I think it'll become clear uh later on why it's relevant to heart disease. But maybe we could start a little bit about uh diabetes. And many people think about it as uh a disease where people are very ill, they need insulin. They think about the experiments from the early 20th century where insulin was discovered and was a life-saving treatment for diabetes. But it's not always like that, is it?

SPEAKER_00 1:18

No, I have to say diabetes, you if you think about diabetes, is a disorder of glucose, fat, and protein metabolism. And uh the problem that drives that is that you either have no insulin, so your body is unable to produce it, and as uh you need to be given insulin to survive, or you have insulin but doesn't work. And of course there is a spectrum in between, but just to keep it simple, no insulin, or insulin is there and it doesn't work. And this uh leads to uh alteration of glucose, lipid, protein metabolism, and leads to the development of vascular cardiac and renal complication. It's a little bit of a very, very slow process and silent. So patients don't really feel when there is an uh this alteration of diabetes with alteration of metabolism, something is happening, uh uh unless the the disease occurs very uh aggressively. Uh but certainly in the long long term the vasculature is slowly, slowly is lowly damaged. Is nothing is is done.

SPEAKER_01 2:38

So Luigi, you mentioned that diabetes is a disorder not just of glucose, sugar uh being high, but it also involves abnormalities in fat metabolism and protein metabolism. Uh so it's it affects a lot of things, not just glucose. Do we know if it's the glucose, the sugar itself, that's the problem in causing uh blood vessel issues and heart issues and other issues? Is it something else? Uh do it what do we know about that?

SPEAKER_00 3:05

If we think about diabetes as changes in glucose level, the tissue that is exposed mostly to these is the lining of the vessel. Very big tissue. And uh so glucose per se will damage the lining of the vessel and the vasculature, creating all the problem, the outcome in terms of vascular cardiovena complication of the patients. Of course, lipids also play an important role in uh in this. Think about cholesterol and uh and how good starting can be to your vasculature. I would say it's mainly glucose and lipids that really drive the damaging in the vascular. The mechanisms are different. We know some, some we understand not as well. And uh but certainly all the changes that we see then will uh synergise and drive uh uh changes in your blood pressure in amodynamic perturbation to the vasculature, making making it all very much worse, for example, at the kidney level, and uh and this will we drive then the vascular complication in general.

SPEAKER_01 4:19

I think that's important, isn't it? Because what you what you talk about is the this insulin resistance phenomenon that a lot of people have milder abnormalities in their glucose, the insulin doesn't work properly. Um, and there's a hell of a lot of people out there who may have this, so-called type 2 diabetes, but not necessarily even know about it unless their their blood's been tested for this.

SPEAKER_00 4:42

Yes, often it's found by chance, or you present UGP with a little bit of maybe candidiasis in your external genitalia, uh or maybe just being light and well or tired. And there have been some studies looking at so if I'm diagnosed to days, how long has it been happening? And it's sort of predicted in some way that uh probably 10-15 years before everything started. So you've been in a limbo between being normal and frankly diabetic, so borderline diabetic for quite many years. And that also kicks in the damage to the vasculature, to the heart, to the kidneys. And uh you often at diagnosis you have already some degree of vascular complication. So you we start sort of this you know we're already in into the disease per se. And clearly we learn that in diabetes, in terms of prevention of vascular complication, which are the ones that then kill the patient, uh we win if we are able to prevent the development, the progression, uh uh and uh the outcome.

SPEAKER_01 6:00

So that's an important point that actually it takes several years for that uh process to damage the blood vessels and the heart. Um and f for those many years, uh if if diabetes was diagnosed earlier, then something could be done about it and prevent all of that. So that's the importance of early diagnosis, isn't it? And I think you mentioned the pre-amble, the the precursor of diabetes, and some people may have heard of the term pre-diabetes. Um so screening is is is an important part of all of that, uh is that right?

SPEAKER_00 6:33

Screening, uh, education, awareness, a lot of things are crucial. I think we are doing much, much better today than many years ago, but can always do better. Prevention is key. Prevention is key.

SPEAKER_01 6:45

And and are there particular groups of people that are more at risk than others?

SPEAKER_00 6:51

Uh yes. And uh it's important to remember that uh uh what damages the vacuum. Yes, diabetes, uh altered glucose metabolism damages your vasculature, heart and the kidney. But if you put that together with, for example, high blood pressure, that is like a bomb on your vasculture, a bomb on your kidneys and heart. And so all this population predisposed to have a high blood pressure, Afro-Caribbean origin, for example, uh uh Asian uh are really more predisposed into the development of the development of chronic complication. So when we see patients, actually, yes we address the altered metabolic control, but we think about also a lifestyle, we think about controlling blood pressure, controlling lipids, a numerous of things that really all the risk factor that drives vascular complication, heart karina complication. We need to address them all together from the very beginning.

SPEAKER_01 7:59

I think that's an important point that diabetes alone is a risk factor for heart disease and blood vessel disease. But in working in concert with other risk factors, it can um accelerate things even more. So high high blood pressure you talked about, um, and other risk factors as well, including high cholesterol and so on. You mentioned um Africans and Caribbeans being at risk, Asians being at risk. I think there's a genetic uh component to it as well.

SPEAKER_00 8:24

Is that soul sensitivity, insulin resistance who drives salt sensitivity, has also been brought into the game. Uh and uh do we know what are the genes? No, we don't know. Probably more than one gene. So there's certainly a strong family history in that and some genetics that drives the development of complicated diabetes per se.

SPEAKER_01 8:52

Aaron Ross Powell So uh family history is important to know about as well as that that that predisposes uh also. I'll turn to you, David, because uh your your uh expertise is obviously in the kidney field and diabetes and kidney disease are very closely linked as well, aren't they? Aaron Ross Powell, Jr.

SPEAKER_02 9:06

They are indeed, actually. And it's nice to be here because Luigi and I pretty much founded the combined clinic here at Guys and St. Thomas Center in diabetes and renal medicine. And it's helpful because um, if you have patients who have diabetes, you're looking for kidney complications. And I always looked for diabetes complications in my kidney patients. Even if they hadn't got formal diabetes, I still would be thinking that you might develop it, especially if you're of a particular, shall we say, age or with other characteristics. So things that Luigi has just told us really apply very much to chronic kidney disease. It's hidden. It's like an iceberg. We can see one-tenth of it, but a lot of it is lying underneath. Of course, if you look for the bit that's underneath, you can find it. But if you go on without screening and thinking, family history, other things that have happened, drugs that the patient may be taking, which can damage the kidney, unless you take all those sort of precautions and have a proactive approach to this, then very sadly, because kidney disease is even, I think, more silent than heart disease and diabetes, it will present at the very end as an emergency. And the problem is there's so much to do and so little time to do it in that many patients uh can't catch up with all the sorts of things they shouldn't have an opportunity to learn, like lifestyle changes to prevent problems. And once you've once it's bolted and got out of control, it's really hard to bring it back. And yet there's so much we can offer if we get the opportunity, if we have time. There are some amazing treatments that are coming through now. Ten years ago, when I sort of was winding down my clinical practice, there was relatively little to offer other than sympathy and good medical care. Now there's several classes of drugs. Most of them I know Luigi borrowed from diabetes. I know that. But nevertheless, they do seem to have a positive impact on kidney deterioration and importantly with uh Albert here, cardiovascular disease progression as well. So it really looks to me, I'm going to be a little bit provocative, to wonder whether there are more commonalities to these conditions than are regimented and segmented, rather siloed the names chronic kidney disease, diabetes, heart disease. Actually, there's an awful lot of overlap. If you did a Venn diagram, there's quite a bit in the middle that we could start perhaps to focus on and might, and it has in kidney disease, pushed us in directions we wouldn't ever have thought we would go. The therapies that are used for obesity and for control of blood sugar are tremendous for kidney patients. And a priori, that's just not what you would have predicted to be the case. But serendipity played a role there. Trevor Burrus, Jr.

SPEAKER_01 11:52

We've heard from Luigi about abnormalities in glucose metabolism, fat and protein metabolism, uh, and all of those things that can uh are abnormal in diabetes that can contribute to blood vessel uh um disease and uh damage. Um from the kidney point of view, what's your take on this?

SPEAKER_02 12:12

Aaron Ross Powell Well, why do we have kidneys in the first place? And we have them because they're there to help regulate a number of factors that are essential for good health. For example, they produce urine. We all know that. But that urine is very important because if you have too little excretion of fluids, you can get waterlogged. And if you have a set of kidneys that can't concentrate urine appropriately, you can actually get very dehydrated. I've seen plenty of examples of that. Then what's in the urine also matters because it's full of impurities and things that the body really needs to get rid of. Potassium is a very good example. If your kidneys fail badly and you have uh lots of bananas, let's say, which are very rich in potassium and can be really healthy, that can cause the blood potassium value to rise very high, and that can then damage the heart directly. So kidneys, I think, are incredibly important. And then you've got a number of other molecules and things that are there from maybe from metabolism that slowly accumulate over time. And as they do so, a bit like uh Luigi's told us about diabetes damaging the lining of blood vessels, these same molecules that are retained by failing kidneys can also do the same thing. They damage what's called the endothelium, the lining of the blood vessels. And that leads to further problems with uh poor vascular reactivity. The blood vessels don't do what they should do when they need to do it. So the further down that you get, the less you have control over volume, the less you have control over blood purity, and the less you have control over managing the very delicate equilibrium you get within a blood vessel. And that is inevitably going to lead you into nasty places, whether it's in one year, ten years, or whatever.

SPEAKER_01 14:06

Thank you, David. So you said that in many ways um chronic kidney disease uh can be silent for a long time until it's quite far advanced. So it it sounds very much like what we were talking about with Luigi here. And so again, it sounds like if we can detect it earlier, we can institute some of the treatments you were talking about earlier, and that might save a lot of people from going on to things like dialysis.

SPEAKER_02 14:29

Yes. I I think when you look at people who present very abruptly and acutely, unfortunately, in the majority of cases, the evidence has been there but hasn't been picked up either at the right time or by the right people. That sounds as though I'm criticizing people, but actually it's such a fuzzy picture that it's quite easy to miss. So, for example, high blood pressure, which as all three of us round the table here talking know, is extremely common in each of these different situations. But that is a real driver of kidney disease. With with my kidney hat on, I would say the kidney is quite frequently the cause of high blood pressure, but other people may have a different view. But that's one thing. So anybody with a family history or anything where they've had their kidney examined before should always keep a weather eye on the blood pressure. And that's something we can easily determine. The other big signal is protein, which should not be in the urine. If you can find protein in a patient's urine, it either means they've got diabetes and complications or they've got kidney disease with its complications. And that really is a big red letter to take very careful attention to so that you can investigate and then intervene. Because it's all about prevention. You're so right, Albert, because you don't want to have to start dialysis. It's a very difficult therapy to maintain in people. If you can avoid a year on dialysis, you've saved an awful lot of heartache and problems that then are partially remediable, but not completely remediable.

SPEAKER_01 16:07

So it's an opportunity we shouldn't overlook. You were talking about uh the fact that you do a joint clinic now. Um what are the important things that that this clinic uh will will do that wouldn't have been done otherwise, would you say?

SPEAKER_02 16:20

Aaron Ross Powell Well, from my perspective, maybe I'll start with that one. Um it it's really a one-stop shop for patients because there's a great deal that runs in chronic diabetes management that I can't offer. I don't have the expertise to do it all. Similarly, um, although it's slightly less the extent, Luigi will benefit from having somebody who has got uh in-depth knowledge of kidneys and also knowing the point at which it's necessary to make a further referral for additional treatments, including an up to the need perhaps for a transplant or dialysis. Now, yes, if we saw people separately, we could achieve all those things as well. But you've got to think of it from the patient's point of view. That's two visits where we could have one. And I'm a great believer in trying to minimize the movement of patients. I think the pandemic taught us that we should, if possible, see patients not necessarily in your own presence. I'm not suggesting videos take the place of everything we do. Some others might, but I'm not suggesting that. But it can be a very useful adjunct. It can help patients who are frail, who live a long way away. I'll just cut a tiny little anecdote if I can. Luigi may remember this patient who came all the way to see us from Cardiff, and he had a hypoglycemic attack while he was in the consultation room. Because the train was late, he'd taken his insulin perfectly, but unfortunately, while he was getting over here from the station, he was unwell. And then what we ended up doing is making sure he had to spend, take fewer visits on the train from Cardiff to London. He could probably see people just as expertly, even as Luigi, a little nearer to home. So I think to try and help the patients, we should be using any approach that we can maximize the quality, but also maximise the opportunity.

SPEAKER_01 18:04

So that may be remote consultations or in-person. And I think what you say about uh combined clinics is is very appropriate. I I think it's it's notable that um these days we're seeing many patients with so-called multimorbidities, lots of things going on at the same time. There is this connection between diabetes, kidney disease, and heart disease, which we'll talk about a bit more. Um, but it is important to remember that we should be treating the whole patient. Um, we shouldn't be treating one aspect. And and because of the interlinking of these these three entities, uh, it makes sense that we should be having combined clinics and treating the patient as a whole. Uh Luigi, if I might come to you. Um diabetes obviously causes a lot a lot of other issues as well. Um, what would you say is is the major um the major cause of illness in people with long-standing diabetes? What's the most important thing? Is it heart disease? Is it something else?

SPEAKER_00 19:03

I think uh what killed patients with diabetes cardiovascular disease. And actually the patients reaching dialysis in a replacement therapy are the protected one, because they made that day. And many of the many of the patients died before that. Heart attack, uh, infect, myocardial infarct, uh uh stroke, uh coronary arteries disease, and gina, and so on, uh the major causes that I think are killing the patient with diabetes. And of course, if you made it to dialysis, you are protected in a way, sort of relatively protected. But then just being on the dialysis, it raises your cardiovascular mortality. It's another physiology. And actually, I thank David for all he taught me during those days. I was really interested. I learned a lot from him and his colleagues. So yeah, it is uh uh devastating scenario. And again, prevention, prevention, prevention, really key. We can't go back wh while we lose, we cannot have it back.

SPEAKER_01 20:14

It's an interesting point uh from what you say that actually if you reach the stage of having end-stage kidney disease and needing dialysis, that actually you've got some genes which have protected you from the ills of heart disease. Um and actually it's important to intervene much earlier. You also make the important point that if you do go on to dialysis, that in itself raises your cardiovascular risk. So there's a lot to think about there. And and David, uh I I don't know what your uh experience in this area is. Would you would you agree with this? Do you think cardiovascular disease is uh is the most important driver of illness and death in the kidney community?

SPEAKER_02 20:54

Yes, it is. I think when people say are over the age of 50, and a lot of my chronic kidney disease patients have been, uh, and that's the point at which their innate cardiovascular disease is then ramped up by the presence of either diabetes or chronic kidney disease, or if if really unlucky, both at the same time, and then it really bolts. And the problem really is that there are a number of problems. One is that not all the therapies that might be used when kidneys are working well tend to work as well when people have got bad kidney disease. A good example of that is statins, which are so important for coronary heart disease. Uh, and of course, people with chronic kidney disease and diabetes are routinely put onto statins for just the reason to protect. But if you get very far down the road of having chronic kidney disease, statins seem to lose their protective impact on the cardiovascular system. Partly, it seems, because the patients with very advanced kidney disease are more prone to sudden cardiac death, which is sort of electrophysiological to do with the circuitry in the heart. And a bit less to do with what we might call, and I have to use this word, an old-fashioned heart attack, a sort of a clot in an artery, which is where the statins are so brilliant, of course, at trying to prevent. So we're not very good at finding the substitute for the statins, as it were. And it just goes back to the fact that the earlier we can deduce that we've got a patient with a lot of potential challenges like cardiovascular disease, diabetes, and chronic kidney disease, the quicker we can get together as a team and try to intervene to prevent progression. Kidneys do decline with age, sadly, but very few people who are healthy will succumb under the age of 90 or 100. It all sort of runs on the similar track. But as soon as you start to get kidney disease going faster, you then get yourself into hot water, bad territory, at the age of 60, 70, or 80. And the opportunity for intervention is slender and it's not as effective. So it's very important. We keep speaking to each other to try and influence this in a positive direction for our patients.

SPEAKER_01 23:04

And if I could take you a uh a step further, and we talked about dialysis, and obviously the step after that is uh kidney transplantation. Um what are the are there cardiovascular risks associated with people having transplants?

SPEAKER_02 23:20

Aaron Ross Powell There are, although I'll be frank with you now. I think they're somewhat overstated. Okay. Because I go back to Luigi's excellent point about the fact that people who get to the point of dialysis have to some small degree got a protection against cardiovascular catastrophes. Now, back in the day when transplants were first a big thing in the 60s and 70s, when the drugs were very uh crude, they weren't particularly effective, there were a number of patients who did badly cardiovascularly speaking. Why? Because they really got to the end of the road, and a transplant was one step too far for them, unfortunately. But of course, at that time, precisely at that time, there was no such thing as long-term dialysis. Dialysis was just a bridge to allow your kidneys to recover, or not, if you see what I mean. So, yeah, I mean, in in terms of the interventions, it's very important to find a way to prevent the need for all of these things coinciding at the same time. So a step a stitch in time saves nine.

SPEAKER_00 24:23

I just wanted to note a little bit a little bit on the concept before about heart and kidney going together. There's a paper in the New England Journal in the 80s. I always speak about this to our students. And there's a very fine correlation between your renal function going down, falling, and your hospitalization for cardiovascular disease, your events and your cardiovascular death increasing progressively as your renal function declines. Very, very close correlation. If you die of a heart attack and you don't reach dialysis, I mean you your kidneys are not perfect for sure. They're wobbling somewhere in the middle. And of course, there is a lot of population variability and so on.

SPEAKER_01 25:28

Because I know that your your research centers around um diabetic kidney disease. Could you tell me a little bit about what you do and what you found?

SPEAKER_00 25:38

We uh for many here have been studying uh molecules that uh are implicated into the vascular repair, uh and to try to find new targets for treatment. Uh what happens in diabetes, all the vessels are damaged, the heart, the kidney is damaged, and you have an activation of repair mechanism. The problem is that the environment there trying to repair what is damaged, the high glucose, there's just lipids, aerodynamic, high blood pressure in the world. Uh all these factors don't make the repair process effective. And actually, that's what we see is the disease itself, the vasculature really falls apart, you know. And even new vessels that are trying to repair are not normal vessels, uh damaged. So the goal in our lab is to try to identify few molecules, factors that are involved in the build up of new vessel and repair. And uh we actually little by little we have characterized them with uh experimental models. And uh we have tried uh mod modulating this still in an experimental models, and we're slowly trying to move towards humans and let's see what the next few years we will bring.

SPEAKER_01 27:13

It's interesting. So you say that the uh the repair mechanisms don't function well because of the environment that they have to work in. Um always the translation to humans takes time. So it it sounds like there's a few years yet before this will uh result in in drugs, is that right?

SPEAKER_00 27:30

Yeah, or be beyond my time for sure. And probably next generation. But uh maybe one day our work and the work by others will give some hints, some new support of new ideas or or tools we might have in 30 years that we don't have today. I mean, if I think of myself as a student, when I was a student, we didn't have what we have today. I'm sure there is somewhere to wait for in the future.

SPEAKER_02 27:57

I I'm very optimistic, actually, about the future. Um I speak as somebody who 10 years ago had almost no drugs to use at any stage of kidney disease. Now we have a suite. Admittedly, we've found them elsewhere, but that doesn't matter. We shouldn't be too proud to use them. Um and what's happened is a lot of things have slotted into place. A realization that a number of rare kidney diseases, if you add up all the people who've got rare disease, it's quite common. If you see what I mean. It sounds a bit counterintuitive. But some of those diseases have got interventions that we can then spread across all the inflammatory kidney diseases. We haven't really talked about those. Those are the ones that young people get that then rob them of kidney function in them in their middle adult years. So that's quite useful. And farmer, the pharma companies, the big companies that spend a lot of money developing drugs, have got together and they've realized that if you get pharma um groups that were previously only studying diabetes and only studying heart disease and only studying kidney disease, you can bring them into a big division and they can all talk to each other and work through some therapies and interventions. And that's really pushed things along a lot. And there's a lot of service redevelopments that are promised, not quite happened yet, but promised, which I think will make it make kidney disease easier for patients to access expertise in. Because at the moment, so much of it, careful how I phrase this, is with general practitioners who are too few in number and too overworked, really, to focus down into the minutiae, the depths of expertise you need to manage complicated patients with multimorbidity, as we've already described. But I'm optimistic that it there is more sunshine emerging in the background there. So give it time. Uh and I think all three of our specialties will actually be able to work better together and also deliver more for patients at an appropriate stage and not leave it so late that you're uh fighting fires that should never have been started.

SPEAKER_01 30:01

As you say, the the drugs that we have now have come on a long way. In the old days, we we had tools like controlling your blood pressure very well, avoiding smoking, getting your cholesterol down with statins. And there are more possibilities now that are directly aimed at diabetic kidney disease. It might be worth just just uh not necessarily going into the mechanisms in great detail, but just listing some of those drugs uh just so the listeners have an idea of what is available now.

SPEAKER_02 30:30

Well, um sodium glucose transporter inhibitors are very important because they're good for diabetes control, but rather remarkably we discovered that they were very cardioprotective in a lot of chronic kidney disease patients. And weirdly, you don't even have to have the diabetes to benefit from them. That was r quite a curveball for us to absorb as kidney doctors.

SPEAKER_01 30:50

Yes, indeed.

SPEAKER_02 30:50

But it actually was instructive as well because now we look for exactly the same thing. The agents that are being used now to curb appetites and to try to ameliorate the excess of obesity have also found a way to protect kidneys and hearts as well. And obviously they improve diabetes by helping people lose weight. So there's a lot of clues coming from these. This is serendipitous discovery, but we we have to look for those examples as well, as you're rather implying, look at the mechanisms and design ways in which to inhibit them. That's further upstream still, rather more like I think what Luigi's talking about in terms of his own lab research. But you have to start at the top with all these things in the hopper, and some of them will percolate down and some of them will emerge as drug therapies eventually. But there's a lot more there. That's really where my optimism comes from.

SPEAKER_01 31:39

So it's interesting. The the two drug classes you talk about are ones which were developed for diabetes and have taken on other lives. The so-called sodium glucose uh transporter inhibitors, SGLT2 drugs like dapoglyflosin, empoglyphlosin, canoglyflosin, um, which, as you said, seem to work irrespective of whether you've got diabetes in in uh preventing kidney physical. And then you've got the GLP1 agonists that everyone is is mad about these days, the fat jabs, which seem to do a lot more than just make you lose weight. They they have uh beneficial effects on heart function, kidney function, and so on. And one of the other um newest treatments that has uh come on the scene is uh a drug called phenerinone.

SPEAKER_02 32:24

Yes, I mean that's a very interesting development because that comes from a sort of um what's called mineral acorticoid component. And that's had a long history for uh a number of rare diseases, but has actually increasingly been usable in the context of diabetes and chronic kidney disease. It's not the easiest drug to use, so you have to get your patient selection really carefully lined up, your ducts in a row in terms of selection. But where you can use it, it has uh additional benefits it can bring to the party. And I think we have to make the point, and I think we're all aware of this, that in the end it's going to take not just one wonder drug to treat these conditions. It means for the patients, they've got to take a whole suite of interventions and therapies. Because this is a complicated area with a lot of interactions, and if you block one thing, it has a habit of finding a new route round the side to cause the same amount of damage. But when we work together as a group, as a group of people and experts, I think it is possible. And what we've got to do now is persuade the people who hold the bills that it is worth this investment in all this additional treatment. To us, it's self-evident that it is because we can see the impact it will have on people's lives. But there are other factors to take into consideration when you're at the government level.

SPEAKER_01 33:43

Indeed. And that's at the mercy of uh government uh spending and health economists and that sort of thing. So it's it's really encouraging to know that uh, as we've talked about, there's um a whole suite of new drugs or new ish drugs that have come on the scene in the last decade or so, which can really make a difference in patients with diabetes and especially diabetes with kidney disease, and can make a difference to cardiovascular outcomes. I think what's coming out of our conversation here is that early diagnosis is really important, that a lot of this stuff is silent, and it's very much the same in my particular field, as I've said in previous podcasts. Hypertension, high blood pressure is often silenced until it presents late with complications. And very much the same is true with type 2 diabetes, chronic kidney disease, and patients who have both. The earlier you can intervene, the better the outcome is going to be in the long term. So I think that's a very important message. Uh Luigi, David, it's been a fascinating discussion. Thank you very much indeed for having joined me today.

SPEAKER_00 34:47

Thank you, Albert, for this invitation and for this uh very interesting discussion. I think the message there is let's prevent, prevent, and uh then we win. Yeah, absolutely.

SPEAKER_02 35:00

Prevention, collaboration. And that's what we've uh the latter part of that, the collaboration, is very much in evidence today from this talk.

SPEAKER_01 35:08

Couldn't agree more, David. Thanks a lot.