Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole, and we have two AHN Physicians for you today to highlight the Combined Inflammatory Glomerular Disease Program at AHN .

Joining me is Dr. Sonia Manocha, she's a board-certified rheumatologist and an Assistant Professor at Drexel University College of Medicine; and Dr. Swati Arora, she's a nephrologist and an Associate Professor at Drexel University College of Medicine. Doctors, thank you so much for joining us today. And Dr. Arora, I'd like to start with you. Can you tell us a little bit about the AHN Autoimmunity Institute and its Glomerular Disease Program? Why did you see a need for this type of program? And tell us a little bit about the primary objectives and how, so importantly, it addresses the gaps in traditional siloed care for these complex patients.

Dr. Swati Arora: Absolutely. Melanie, thank you so much for having us over today. I'll start off with where is the need and where's the gap? So when we talk about autoimmune diseases affecting the kidneys, in the bigger scheme of the world of kidney diseases, these are still very rare diseases. And what that means is that if you are in your training or if you are practicing in a community hospital or any other office setting, say, out of a hundred patients, you might have maybe a couple of the patients with these rare kidney diseases. So as you as can see, if there's not much interaction with these complicated, challenging patients, then that that leads to delay in the diagnosis and then the further treatment plan.

So, this is where I would say even back in 2017, I would say that we all got together and it was like a lot of these autoimmune diseases have multi-organ involvement. So, it needs specialists from different fields. And it's pretty much like if you were building a house, you need an electrician, you need a plumber, you need someone for roofing. So, thinking of that patient on the same lines. You need someone to take care of their skin and then their kidneys and then their lung part, their GI issues, right? So, all of us got together with Rheumatology as being the main stem for it because autoimmune diseases in general are overlooked by the rheumatologist. So, we all got together under this one umbrella of autoimmune diseases. So, this is where we partnered with my colleague, Dr. Manocha, to start this combined program where we're addressing people with autoimmune diseases who also have their kidneys involved. And we felt that if we could do this together as a team, it'll serve the patients better, and it obviously gives us more satisfaction.

Melanie Cole, MS: Absolutely. And I love your analogy about building a house. We talk about a multidisciplinary approach a lot of times on this show. But really, the way that you put it, Dr. Arora, really makes so much sense to other providers. And Dr. Manocha, you represent different specialties here focused on treating glomerular disease. How is care co-managed between Rheumatology and Nephrology? Walk us through a little bit of the program and why this multidisciplinary approach is so important for these patients.

Sonia Manocha, MD: For sure, and thank you again for having us. This multidisciplinary approach really is very important for these patients. As Dr. Arora mentioned, you know, they have a lot of different organs involved and organs, you know, like the kidneys or the skin and so forth, but they're all autoimmune.

So, it's really important to have multiple different specialists come together for this care as we're treating just one patient at a time, right? For us, it's wonderful to have this combined care together with this glomerulonephritis autoimmune clinic. Because this way, we can work together at the same time in real time, talk to the patients, get a good history together, and actually be able to take that and turn it into a good comprehensive management care.

Melanie Cole, MS: Such an important point. And Dr. Arora, from your perspective as a nephrologist, how has integrating Rheumatology into the care model improved early diagnosis and long-term kidney outcomes? As we say, these glomerular diseases involve many organs. But in your experience and perspective, how has incorporating Dr. Manocha into this really changed your outcomes for the better?

Dr. Swati Arora: I have like a million of examples to go over, but I'll pick couple of them, okay? So, the first I would start with, in our world, we believe that the basic unit of the kidney is a nephron. And we think nephron is time, meaning the sooner we diagnose people having kidney involvement, the sooner we treat it, the more we save these tiny units which help in filtering the blood and cleaning the blood. So, the way it helps to work together with Dr. Manocha is that, as an example, she's seeing someone with lupus. And then as a routine testing, she sees a tiny bit of microscopic blood in the urine. And that's when it rings a trigger for us to walk in together. And then, I would look at the urine under microscopy. And if I see concerning blood cells, we can talk to the patient early on, maybe do more testing, including a kidney biopsy. And then, sooner we diagnose it and treat it, we are saving the nephrons, these filtering units, in the long run. That's one aspect where I think it is definitely helping us to catch these patients early on before they are reaching at late stages.

The other example I want to take is if I'm seeing a patient and, from my perspective, they're doing beautiful, and I want to lower their dose of let's say prednisone, that's a steroid. We want to minimize the use of prednisone as much as we can. And then, usually, in the past, I used to say, "Okay, I'll send a message to your rheumatologist. And then, we'll get back to you," which means there's an easy delay for few days, sometimes weeks, and sometimes, you know, with communication gap, things would go apart. So with her, with Dr. Manocha, literally the bedside of the patient with me in the same office room, I'm like, "Sonia, I think we can go down. What do you think from Rheumatology perspective?" And then, she'll give me her thoughts. "Yeah, we can lower it now or maybe I want to wait for some time." So, I love that combined decision-making, and then I'm not waiting on for a nurse to go to B nurse, then to the doctor, and then to my nurse and coming back to me, and then to the patient. So, all that is kind of bypassed and the patients are happy. And they feel, "Yeah, I am being seen with two people, and I'm being advised what to do." And similar thing applies if I have to, say, escalate their immunosuppression, add more medication, then I have full support to make this decision side by side.

Sonia Manocha, MD: Absolutely. I couldn't say that better. I mean, it's just having that communication at the bedside really to me speeds up diagnosis and then furthers treatment as well, and it just allows for the comprehensive care.

Melanie Cole, MS: It is such a comprehensive approach. But along those lines, Dr. Manocha, how has working closely with Nephrology shifted your approach to managing systemic autoimmune diseases that could impact the kidneys? Because, obviously, you too used to kind of work in silos. This was not something that was brought together, so this is really unique and very special.

Sonia Manocha, MD: Absolutely. I agree. Prior to having this combined clinic, just as Dr. Arora mentioned, we'd be communicating through the medical charts or over the phone. And it's not as fast, it does delay things. So with this combined communication, combined clinic, everything is so much quicker. And not only that, as Dr. Arora mentioned, one of the things that she does during her clinic is we'll get a sample of urine at the start of the visit. And she's able to spin that down, look at it right away and we can see from that urine is there anything that's concerning for an active inflammation within the kidneys that needs to be acted upon right away? And that really can lead to whether or not we're going to pursue a kidney biopsy or further testing. And in addition to that, I'm there in the office too. I can look at them, see if they have active rashes or any other symptoms of more of the systemic aspects of their condition to see how we need to approach the patient as one patient as opposed to just their kidneys or just the skin manifestation. So, that to me, just brings everything to another level.

Melanie Cole, MS: It's so interesting. And Dr. Arora, this is an exciting time in both of your fields. So many advancements, so many tools in your toolbox. Tell us some of the latest or most exciting advances right now and what role the program plays in incorporating some of these novel therapies, including biologics or immunosuppressive therapies. Tell us a little bit about what's exciting in your field right now.

Dr. Swati Arora: There's so much going on. So much is in the pipeline. As an example, I would say before 2020 maybe, we had couple of drugs which were FDA approved for in the world of Nephrology. And since 2020, if I count on my fingers, it's close to six or seven new drugs, which got approved for patients with inflammatory kidney disease or glomerulonephritis .

Usually, when a new drug comes in the market, and as a provider, when you are making the decision whether I should start this for my patient or not. So, you're still building your own personal experience, you know, with the goal of benefiting the patient first and avoiding the harms. You always debate in your mind, "Should I go ahead or not?" But when I'm working with another colleague, like Dr. Manocha from Rheumatology, then I have her input from Rheumatology perspective. And then, I add my thoughts from Nephrology perspective. And to be honest, about a third of our patients end up getting on these new therapies, because the patients also feel more comfortable when you tell them, "Yes, the drug was just approved last month, and we're thinking to start on you," when this comes from two physicians together, their acceptance level is better as well.

So, I think in the end, it almost, to me, feels like that we have the luxury of having that support from each other. And there are times when I feel, "Okay, I do want to do X, Y, Z." And Dr. Manocha is like, "No, no, no. There are things going on outside the kidneys. How about we try this first?" And I'm like, "Sure we can, but I need labs again in a month." So, it's not like we are always in agreement with each other. We have our ways of talking to each other in front of the patient. I don't think we ever have that feeling of embarrassment or anything like that. It's almost collegial. So, I absolutely love that interaction. And I think it has definitely opened the door for starting new therapies.

And I also want to mention we have ongoing clinical trials. And whenever we are enrolling a patient, then we always discuss with each other, "Do we think we want to stick on what we have or do you want to put this patient in the clinical trial?" So, it's actually helping us from multi-directions, and with a whole goal of benefiting the patient.

Sonia Manocha, MD: Absolutely. And I mean it's a three-way conversation. It's between the two of us and the patient all at the same time. So that way, we have everybody's input, everyone's buy-in with these new treatments and new options. And like you mentioned, there really are a lot of new options available that are FDA approved, which is just a wonderful new horizon for the field.

Melanie Cole, MS: While you're working together and because that's so important when patients get diagnosed, whether it's with kidney issues, whether it's glomerular and rheumatic together, whatever this is, it can be scary and confusing for patients. Dr. Manocha, please tell us a little bit about your Nurse Navigator Program and how they help patients. Because getting appointments and seeing you both and navigating the world of immunosuppressant drugs and just all of the treatments that they might be going through can be quite confusing.

Sonia Manocha, MD: That's a great question. You're absolutely correct. You know, these patients, oftentimes they're very young. So, lupus is a disease that oftentimes affects women of childbearing ages, affects men as well. But what I'm getting at is that they're generally a lot younger. And that being said, there are a lot of different aspects to their care here, and it is very emotionally draining for these individuals and their family members. So, we oftentimes see the patients come in by themselves. But then, more times than not, we have them with their care team or their support group from home, so their family members or friends, whomever comes in with them.

It is essential to their care that we address some of these other factors as well, either support that they might need outside of their own family, if they need to see a therapist, for instance, or if they need a nurse navigator like you mentioned, someone to help navigate the health system, which is it's very difficult to figure that part out. Also, help with obtaining medication. So, we may come up with a wonderful plan to start a new treatment, but we still have to go through a process of authorization, go through the insurance companies, obtain the medication, get some assistance with the payments, because these are not inexpensive medications.

We have been extremely lucky within the autoimmunity institute to have a care team available that helps us with these things. We do have a nurse navigator. We also have a clinical pharmacist that can help maneuver through this, a social worker and a behavioral health team, and a dietician. So, I absolutely love getting them all on board and helping to really treat the patient inside and out.

Melanie Cole, MS: It's so important when we're thinking of quality of life of the patient. And I think that you just made that very clear about how you really help guide them and how your team, because it's really just a team effort. And Dr. Arora, from your perspective, what do you see as the broader impact of specialized programs like this when you think about horizon and outcomes for these patients? Why do you see this as being so important?

Dr. Swati Arora: The biggest impact that I have noticed is, you know, a lot of these people who are young, they are in denial. So, they were just fine. And now, they have to be on four different medications. And we talk about big time side effects. "This could happen. That could happen. But you need it," right? And sometimes, especially with the kidneys, the symptoms may not be as much. All you notice is abnormal blood work or urine tests. So, there's a big time denial, right? And denial leads to noncompliance, which means, "I don't need a doctor. I don't need to take any of my meds. I am just fine." And when people are moving with that thought process, it's actually detrimental, right?

So when you hear something from one person versus two people who are giving you that broader picture, I think it helps them in accepting that, "Okay, I have this condition and there are two experts in the room who are talking." And believe it or not, me and Dr. Manocha have a very similar format where we come up with different examples, which people can understand. And once that understanding is there, acceptance is there, that improves the compliance.

So, we actually looked back in our patients over the last one year. And the compliance rates were close to 100%, which was shocking for us. We're like, "Really?" So, that is amazing. And two, because we feel that patients are doing a better job in following the directions, and I want to give this credit to the patients as well because, yes, we prescribe, but that doesn't mean that patient is taking it. So, the taking part is important. So when the patients are following the directions, taking their medications, we have seen that we can significantly bring down the prednisone to minimal dose or none doses. And usually, that's the place where I think we're making an impact by having that special bonding. And sometimes I call this as-- to the patient that think of us, we're co-parenting you. We're your parents here wanting to help you. We understand it is hard, but we are here. And it really works and it's so, so gratifying for us as a provider.

Melanie Cole, MS: I can hear the passion and the compassion in both of your descriptions of this program. It is really amazing. Now, Dr. Manocha, I'd love to give you each a chance for a final thought here. And Dr. Manocha, what's your vision for the program? How will this care model do you feel improve the way patients receive their care for comorbid conditions also that come along with these diseases? And what would you say to other healthcare systems looking to replicate this model, the most critical components for the success as you have seen?

Sonia Manocha, MD: Wow. Well, I think that this model, it's something that is very, very important to me. And I love the idea of comprehensive care in general. So, I think this model allows for that. And I think there are a lot of different areas that could benefit from a combined clinic modality.

For us, in particular, I really hope that this continues as it can provide such great care for our patients with lupus, with vasculitis, and with other autoimmune kidney diseases. And I feel like this can help lead to better levels of remission in these patients, less use of things like prednisone or other steroids, which we found kind of over time are more detrimental, which is why we're so very happy that we have new medications in the pipeline here coming through. But also, this kind of a combined clinic will also allow us to continue to look for new medications, to do these clinical trials, and to help our patients moving forward.

The important points to have or the important building blocks for these types of clinics, I think are, number one, having amazing physicians to work with. Having wonderful colleagues in the field really is important, and that I'm lucky to have here. In addition, having the care team that we talked about, different people like the nurse navigator and so forth to help provide that care and make it more of a well-rounded approach is also essential.

Dr. Swati Arora: Yeah, exactly. I agree with Dr. Manocha and I would like to add that to start a program like this, so as an example, even before this program was in place, me and Dr. Manocha were trying to sneak in each other's patients' rooms to see the patients together. But I think a round of applause goes for the administrative staff. They have put in a lot of hard work so that our schedules are matched. We had a lot of hurdles early on. As an example, if me and her are seeing the same patient at 9:00 a.m. Then from Billings standpoint, you cannot put them on the same slot for two different physicians. Then, we had to make sure that we are at the same facility. It's not like I am rounding at a different hospital and Dr. Manocha is at another place. So, we had to be the common location. And then, there's a lot of collaboration that was needed between the department at the Division of Nephrology and Rheumatology. And then, so big round of applause, starting from medical assistant to our administrators to help support in bringing this live to our patients. And to this day, when I tell patients, "Would you like to come see Dr. Manocha and me together?", they almost have this pause and little sparkle in their eyes, "Is this possible?" And I'm like, "Yeah." So, it's such kind of a concept which sounds very new, but I think we needed it all along.

As Dr. Manocha said, this could be applicable to multiple sub-specializations. Like I have patients who have heart failure and kidney disease. So, can a heart doctor and kidney disease person be together? I have patients who have diabetes and diabetic kidney disease, so can an endocrine and nephrologist work together? So, there are lots and lots of pathways there, which I think we're successful in developing them. Then, it'll be a totally different and more fulfilling environment for everyone.

Melanie Cole, MS: Well, it certainly will. And just lastly, Dr. Arora, what would you like other providers to take away from this really exceptional discussion that we've had today? And what makes your program, I mean, you've just told us what makes your program so unique from others in the Western PA region. However, I would like you to just give them your best advice, what you would like them to know about the program and why it's so important to refer to the specialists at AHN .

Dr. Swati Arora: Absolutely. So, I feel that there are a lot of patients out there who can have very subtle symptoms and they would not come to our attention unless they have, say, a routine screening or routine exam for something else. So, I would say if people have subtle symptoms, even like microscopic blood in the urine or mild amounts of protein in the urine, or if you're talking about a rash that comes and goes, or they are stiff in the morning at a young age. So, those are very subtle symptoms, which I feel need to be picked up on early.

And a lot of times it's a struggle for especially the primary care physicians, to tell the patient, you have to go see a rheumatologist and a nephrologist on two separate appointments, which could be months apart, versus you tell them we have this program where everybody collaborates together and, yes, you might have to travel on that one day, but you will be seeing two different physicians in the same room at the same time, and the best part is the communication with the primary referring physician and us. So, I think that will certainly help us in improving the patient care and improve their compliance.

Melanie Cole, MS: It certainly will. And thank you both so much for joining us today and really sharing your incredible expertise for other providers. And to learn more or to refer your patients to the AHN Autoimmunity Institute and its Glomerular Disease Program, and Dr. Manocha and Dr. Arora, please call 844-MD-REFER, or you can always visit ahn.org. Thank you so much for joining us on this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.