Patrick Short  0:03  
Hi, everyone, and welcome to the genetics Podcast. I'm really excited to be here today with Mike Spigler, who's the vice president of patient support and education for the American Kidney Fund. The American Kidney Fund or AKF, if I'll probably shorten it a couple times in here works on behalf of the 37 million Americans that are living with kidney disease in the millions more that are at risk. And I think they just have an incredibly impressive scope of programmes, supporting people all the way from awareness and prevention all the way through to post transplant living and helping patients who are on dialysis. Mike in particular oversees a wide spectrum programmes and services as well prevention activities, very successful and top rated health educational sources, as well as a direct financial assistance programme that I mentioned. I'm really excited, Mike, to have you here. Thanks so much for joining me and taking the time. 

Mike Spigler  0:48  
Well, I really appreciate the opportunity. And looking forward to our conversation today.

Patrick Short  0:52  
So I gave a short overview, but I don't think I could do it justice, the amount of work that you all do, I'd love if you could just give a little bit of an overview of the American funds mission. And then I'd love to hear also about how you got into it. 

Mike Spigler  1:03  
Sure. Well, the American Kidney Fund, really our tagline is fighting for on all fronts. And we really think that we do that, you know, we have a wide range of programmes that start with just awareness about kidney disease and kidney health and prevention in general, all the way up through chronic kidney disease. And then, you know, should you end up on dialysis or a transplant, lots of education and support there, we have programmes not only that, educate patients, but also healthcare professionals, as well. And, you know, unlike a lot of other organisations to, you know, where you get through everything else, you've got all the education programmes there. But at the end of the day, you just need someone to help, you know, pay for bills that you can't afford. That's really where we step in and kind of differentiate in one way as well, is our financial assistance programmes, we offer assistance to one out of every six dialysis patients in the US. And what I'm most proud of about that is we're on pace this year to help about 2100 of those patients end up with a kidney transplant by the end of the year, we had 1900 last year. And we're ahead of pace on that even this year, too. And if you look at those patients that transplant, they are kind of upside down from the rest of the world. And the disparities that you usually see in transplant aren't in the group that we serve. So they're much more likely if you were African American or Hispanic Latino, to get a transplant with our assistance than kind of the general population to so you know, because we have this kind of 360 degree approach to all the programmes that we do, you know, we have a pretty good touch point with with the community. 

Patrick Short  2:29  
One of the major initiatives that you've been working on relatively recently, I think, kicked off in 2021 is the unknown causes kidney disease project, and everyone who listened to us knows that we spent a lot of time on genomics and precision medicine. Obviously, genomics and genetic testing is a key part of kidney disease. Maybe you could talk a little bit about about that programme. How did it come about? You know, maybe you could talk through the four key pillars and some of the motivations behind starting this programme?

Mike Spigler  2:57  
Yeah, absolutely. So it's a programme that I'm very excited about, I think it's something that has really taken off here at aka, if it all started, because that financial assistance programme that I talked about, we actually collect a wide range of data on our patients. So I know everything from the modality that they're on for dialysis, to the insurance type that they have to everything about their finances, I can tell you how much a patient you know how much gas they put in their car every month. But from a health standpoint, we also have all their comorbidity data and the primary cause of their kidney failure. And as we started to go through this kind of robust new system that we built out in 2018, to collect this data, one of the interesting or scary things that I we started to look at that was the primary cause of kidney failure. We had 14% of our patients did not know what caused their kidney failure. And when you look at the United States renal data system numbers on that it shows 5% Don't know, so got us thinking, you know, is there something going on with our particular patients? Because they are a poor population? I mean, our patients their annual household income is $25,000 or less, they, you know, predominantly from communities of colour, was there something special happening there? And as we started to go through this project, actually, what we've started to realise is I think our data actually might be more accurate. It's not so much necessarily our population is having a hit on it. So you know, we started this project, we put a steering committee together some patients, some leading researchers in this area, Dr. Holick, Ra Olick. Ravi from Columbia University was one of the steering committee members on this industry. And we put together this group of of really key people to say, how can we solve this problem? We did a summit in December of 2020. we broaden every rare kidney disease advocacy organisation, we had several federal government agencies there more industry, more patients, more researchers to really think about what are the causes of this just generally in the population, and especially what might be happening in our population? And what can we do about that? So a couple of the key things have come out of that. Dr. gravi, at that summit, presented some research of his own looking at some of the genetic makeup of patients and seeing a a broader, much broader amount than 5% that may have some kind of a genetic opponent to their kidney disease. And, you know, we came up with a white paper, which we caught our roadmap for solving this problem. We did a release of that in July of last year, and have really now instead of just doing the white paper and walking away, we've really started to put some programme effort toward that to implement it. So we've worked with with three groups, one for patients and caregivers. And that group is really trying to empower patients to be able to confidently ask for a second opinion, to get a family history to understand the importance of knowing what caused their kidney disease, we have some policy efforts going on in the second group, which is really trying to get more protections for these patients, but also some more coverage for genetic testing and genetic counselling in Medicare and Medicaid, which is not the same as you would find in private insurance right now. So there's some big gaps there. And then the last piece is around healthcare professionals. And the reason why I said I think that we maybe have more true data than the US rds, we did a survey just we just published it in March. And we asked 300 health care professionals and these are wide range of primary care, nephrology, transplant surgeons, urban settings, rural settings, it was a really great mix, thinking about their CKD patients, you know, what percentage do you for sure know, the cause? Of which percentage do you think you know, but you're not 100%? Sure. And what percentage do you have absolutely no idea what caused their kidney disease out of that wide group of healthcare professionals 15, they said, 15% of their patients, they have no idea what caused their disease. It's about another third where they think they know, but they're not really sure and only about another 40% or so, where they confidently know it. So, you know, we now have genetic data from from researchers like Dr. gravi, we now have this, you know, this survey data from professionals across the country saying that, and maybe it is toward that higher amount. And you know, I've done some presentations on this. And I always had people come up to me afterwards and say, Well, I think I know what it is. It's these patients that are, you know, crashing into late stage kidney disease or dialysis, they show up in the emergency department or to the doctor's office, they have high blood pressure, and with no other history or anything else, they go, Oh, well, it must be high blood pressure to cause the kidney disease, when in fact, it's a kind of maybe a chicken in the egg scenario, and the kidney disease is there and it's causing the high blood pressure. So if you look at that pie chart of the USRDS, the causes and you asked me kind of, you know, where do you think that that change may happen? I think it'd be in high blood pressure. But there's still a lot more work to be done there. And now we're starting to work on taking results of that survey using CME programming as well. 

Patrick Short  7:28  
I'm glad you brought the survey because it came up in my research, and I thought the quote from from Dr. Silis, Norman, who I think is, I believe on on the board at a kf and he's also a medical director of kidney and pancreas transplantation at University of Michigan, he referred specifically to the importance of genetic testing. And I thought one of the really interesting things about that report that fits my experience with other disease areas as well is that healthcare providers often aren't comfortable ordering tests, interpreting tests, and they're willing to admit it right. It's not that people are, are saying, you know, we don't need it. They're saying, we think we do need it, but we don't maybe don't have the training. Maybe you could talk a little bit about that. Why? Why has it taken so long to get the first human genome was done in 2000. And it started to get reasonably cost cost effective, you know, five, or maybe even 10 years ago, depending who you ask what you think is, is needed to really haven't hit the mainstream?

Mike Spigler  8:24  
I think there's a lot of reasons for it. I think, from the professional standpoint, in that survey, we also asked, you know, what do you view as barriers to having your patients get genetic testing, and it was in the 90% of doctors that said, they didn't think it was affordable, the out of pocket costs were too expensive for patients. But to your point, you know, the costs have really come down for that there's a lot of companies that are offering it, you know, through some partnerships with with some rare disease pharma companies for free, but that perception is still there, that it's not really achievable. from a cost standpoint, I think that's a big part of it. I think we don't have enough genetic counsellors, I don't think we have enough genetic counsellors familiar and renal, you know, I actually talking to Silas, who you mentioned, you know, they've looked at trying to implement a programme there where, you know, they would do genetic testing as part of any living donor kind of coming in. And, you know, they're struggling even themselves with having enough genetic counsellors there to pull that off effectively. So you take that upstream to, you know, primary care or something like that, where they might even know that genetic tests exist, it's just not going to happen. And the other major problem, too, I think is, you know, the survey also found one and not just our survey, I mean, there's been a multitude of surveys long before us that have showed that primary care not referring patients in nephrology until very late I mean, the majority of our pay the people that we surveyed, and they said they weren't referring patients till stage four was probably the biggest segment but all three B five, so you know, you're not getting to a nephrologist, is probably going to have more comfort and awareness of these genetic tests. So pretty far along so I think that's, that's a big part of it, too. It's Because of genetic, the genetic counsellor is such an important part of it, right? You want someone on the front end to make sure you're getting the right test done, and a genetic counsellor on the back end, when it comes back, you can actually easily interpret it. So it's making sure that the finances and the genetic counselling is and the right person that's kind of all in the right place at the right time. We need some protocols from a community to start to figure out exactly who, what, where, and why and how genetic testing happens to solve this.

Patrick Short  10:24  
Do you have a sense within the, you know, 14 15% of people that have an unknown? Cause? Do you have a sense of what proportion of that might be genetic? Because you said something really interesting earlier that I think based on the epidemiology, there's probably a good chunk of those individuals who have a rare genetic kidney disease, right, and something like exome sequencing could find it. But then there's also genetic factors that are going to be present in every member of the population. And so even outside of that 14%, you might have within the 86% people who are, you know, they know their cause, but actually genetics may be a contributor or partial cause. And they don't know about that. I'm curious whether, you know, you and the, in the group you've been working with have done any estimates or digging into what that you know, what that unexplained fraction could look like.

Mike Spigler  11:14  
I mean, it's hard to tell, right, but to your point, sure, it could just be a standalone rare disease, it could be something like a pol one, which is causing progression faster in some patients. So well, it's not a genetic disease in and of itself that's causing, you know, progression of CKD faster. Anecdotally, when we did some of the patients that we another key part that we looked at when we first took this programme on, is we looked at our patients who knew the cause of their kidney failure versus those that didn't, there was a higher percentage of patients who had lost one or multiple transplants that did not know their cause versus those that do. Now, we anecdotally just kind of picked a few of them and reached out to them. And we did find some patients that had something like FSGs, they were diagnosed as having high blood pressure, even though they never had high blood pressure diagnosis before went to the emergency room in kidney failure, got a living donor transplant, lost that living donor transplant, because there are FSGs, which had never been found before attack that kidney as well. So it's certainly possible, I can't say, you know, for sure that that's what's happening. It's certainly the hypothesis, though, I will tell you.

Patrick Short  12:17  
Well, and I think you're, you're gonna find that out as you start to roll out this programme, right, which is really exciting. And I think a great step in the right direction that if you can start to even put some rough quantum as to what what is the source of the problem or set of problems within this group, then you can start to come up with an action plan of okay, if it's if 5% of that Mar are rare diseases, then how do we ensure patients who are most likely to have one of these rare diseases get access to genetic testing, if you know another 5% is something else, you you, you can really start to make a plan where previously, you've just got one in six people saying I don't know what's causing this. And and that's the end of the road, basically. Absolutely. I'd love to talk a little bit about in the initial kind of white paper or document that you outline the plan, you highlighted the fact that black Americans are 4x more likely to experience chronic kidney failure. What are some of the drivers behind this? And and, you know, what, what are you already doing and thinking about doing to try to address that?

Mike Spigler  13:18  
Well, it's obviously combination of factors, we could probably have an entire podcast about why that is, I'm sure you know, but you know, I mentioned just, I want to start with just the the scientific part of it, and then really go into the kind of the social aspects of it, you know, the APO a Pol, one gene, which I'm sure if your listeners are not familiar with is, you know, a gene, predominantly from patients have of recent African ancestry that had some protective benefit, you know, from a genetic standpoint, for patients that are living in Africa from a sleeping sickness, but has been shown to cause kidney disease progression to be faster, especially in diabetic patients, but also, you know, patients with things like FSGs. So I think that's, that's a key factor, at least not so much as the onset, but certainly the progression into kidney failure. But obviously, you know, there are major issues here in our healthcare system, that from a racial standpoint, you know, harder to get access to specialists. I mean, if you are African American and poor, and then you are on Medicaid or some kind of a programme like that, it's harder to get into SSI and nephrologists, you may get a later referral, you know, there are just some very simple health benefits here that that many of us enjoy that that other populations might not, I mean, you know, everyone always says eat healthy and exercise, that might not be a viable option to a lot of patients if they're in a food desert. You know, there are also some some cultural competency issues. I think that happened. You know, there's just a lot of things happening. Of course, there are higher rates of diabetes and high blood pressure in those populations as well. But again, managing them requires access to some healthy options and a lot of times those things aren't there. You know, I the main kind of formula for determining whether or not someone has As kidney disease was the EGFR calculation, estimated glomerular filtration rate, you know, there had been for years and years and years a coefficient in that equation for African Americans that was basically falsely inflating their numbers a little bit. So for me as a Caucasian that medicine, I was in stage three, and for them, it's going to say, stage two, you know, there, there was some relatively strong science behind them. And the creating the numbers are higher, just as a baseline African Americans versus Caucasians. But to translate that into an EGFR just doesn't really seem like a fair thing to do was a unnecessary kind of othering. That was put in and I think that will help too, because if you know if patients are qualifying to see a nephrologist earlier to give them a kidney transplant list earlier, because the numbers are more accurate, I think that will go a long way to so it's it's the science, it's it's the kind of systemic racism that has that has caused some disproportionate consequences on these populations. And then just some, you know, unnecessary errors. I think that we've done in the healthcare community, both things like the EGFR calculation, have all played a role.

Patrick Short  16:08  
Is there an area of the spectrum from early, early diagnosis, detection, prevention, all the way through to transplant dialysis support that you feel like the most attention is needed as I was preparing for this site? I think one of the amazing things that you all do is you cover such a broad spectrum. And I think that's probably because somebody sat down said, no, there really is no one place, we really actually need to look at the whole system. But I'm curious whether there are some areas that you know, are maybe more urgent than others where we can make a bigger impact sooner?

Mike Spigler  16:41  
Well, I think one of the things is we have to get patients the full range of testing available to them, when they go to see the doctor. And when we did the survey that I was talking about, we did a qualitative phase two. So we did kind of one hour interviews with primary care nephrologist, urologist, we cast a very wide net in that initial phase. And one of the things that we found was every primary care doctor that we surveyed, and we had a conversation with said, Yeah, I don't really do any urine testing, I probably have patients in stage one and stage two, but I wouldn't know, you know, we do the EGFR and if it comes back as being, you know, low, then you know, we'll refer to nephrology, stage three, B four, something like that. And I think that's a major problem. Even in our survey, we, you know, we looked at who's getting like a complete metabolic panel and getting that blood test versus those that are getting the urine tests. And I have seen that happen in my own life with my own family members who aren't getting that that urine test done, you know, you're never going to find stage one or two, if you're not doing the urine test to kind of company it. So I know there are several organisations out there trying to push for more standardisation of that, if we can at least get standardisation in high risk individuals, we're getting a little bit of better in that if you're diabetic, but not so much. If you have uncontrolled hypertension, if you're in one of these risk groups, you're that's just not happening. So, you know, we're in a place right now that we weren't in 15 years ago, we did not have the innovations that we have now we did not have the genetic testing abilities that we have now. And I think for a lot of doctors that have been in health systems to I don't wanna put it on the doctors themselves. Sometimes these are directors coming from their health systems, there's just hasn't caught up to the to the innovations that we have here. There are medications now to help tremendously with diabetic kidney disease at a minimum. But frankly, I mean, there are things like metformin and aces and ARBs that aren't even being applied right now at a standard level. So, you know, it's one thing to find the patients is the other thing, then to make sure they're getting the right treatment on top of it, too. So it's, it's all of those pieces, and we just have to do a better job of trying to get these innovations out to physicians, because they feel like they have tools they're going to be to treat they're gonna be more likely to identify. So I think that's a big part of it.

Patrick Short  18:51  
And why do you think that is, is because incorrect if I'm wrong, but it strikes me that it wouldn't be a wouldn't necessarily be a cost issue, right? You're in your analysis is not expensive? Is it an incentives issue in the sense that you're there? It third, like like your stats, say 37 million Americans? And you know, maybe there aren't great treatment or prevention strategies. So do people throw their hands up a little bit and say, like, Yeah, we could do these urine analysis, but, you know, what can I do about it? Or is it is it lack of awareness? What Why is it that we've got some of these obvious tools, but they're just not being applied?

Mike Spigler  19:27  
I think it's a it's hard question to answer. I mean, I think I think it's certainly somewhat lack of awareness. I think there's also a fear of overdiagnosis. Well, we find these patients were going to nephrology, you know, there is a lack of nephrologists in the US right now. I mean, that's for sure. It could be that too. But that's why we have to really think about how do we appropriately triage these patients Okay, then let's not deal with everyone but, you know, if you've got a patient with family history of kidney disease, or they have high blood pressure, you know that then we have to think about at least trying to focus Going on those patients. And so you're right, it's not really a cost issue. It's just that the guidelines aren't there to push it out unless you're diabetic. And we've got to really work together as a community to try to fix that.

Patrick Short  20:12  
Right. And that's where you can get kind of frustratingly asymmetric outcomes, right? Where one you know, and it's very often socio economically divided. But sometimes, you can also just be random, right, where you're one doctor has actually died. And I think you shared a personal story, if you don't mind me sharing it, I was as I was prepping. I think one of the things you said that got you, you know, maybe passionate about this space in the first place, is that I think your mother was affected by chronic kidney disease and wasn't getting the care and attention that she needed. And if you hadn't been there to advocate for her, then, you know, it just probably wouldn't have happened.

Mike Spigler  20:52  
Yeah, so and it's the sad part about this is, as I've told the story, I've heard multiple people will recount, you know, similar stories, so I am the primary caregiver for my mom, I became that. So suddenly, my dad passed away about four or five years ago. And you know, I moved her down closer to me and Secretary primary care appointment. And just a little background on my family, my grandmother died of diabetic kidney disease while on dialysis. My mom had high blood pressure and uncontrolled diabetes. So all the risk factors should be you know, sending alarm bells out about kidney disease, and I'm in the appointment with my mom, she's had her bloodwork done, and the doctor is going through everything and he says, oh, yeah, your kidney, kidney function is off a little bit, nothing to worry about, and just was going to blow right by it. And I, you know, I said, Hold timeout, you know, the wrong guy in the room to kind of blow blow by that piece. And she was in stage three a of kidney disease, but she was on medications that were going to exacerbate it, you know, are some arthritis medications that were gonna exacerbate it, we got her off that those meds and switch things up, she progressed a little bit in stage three, B, but she's been there ever since. And, you know, unfortunately, she has multiple other issues. Now, Alzheimer's is really the key problem now. But you know, we kept her off dialysis because she was on a trajectory. And so it's, it's not just having the test done, I think you bring up a good point that that's a part of it. I mean, these tests may be deep being done, but the test has to be done, and the doctor has to communicate it. And even if that's happening, the doctor has to communicate it in a way that the patient can understand. I mean, even my neighbour I, you know, came to me and he said, Yeah, I'm going to see some Neff something, I don't know what it's for, or why you have any idea what that does or what they're for. And I was like, Okay, that's a kidney disease doctor, let me look at your lab results. And he was in stage four. So I mean, you know, it's just, it's one thing to have a test, that's the first barrier. So they're gonna be told that you have a bad result. That's the second thing. And the third piece has to be done in the way that you understand it. So to have all three of those things happen, I think, is a big challenge. 

Patrick Short  22:49  
Yeah, I think you're spot on about that. And thank you for sharing the story about your mother. I'm sorry to hear about the Alzheimer's i Is it fair to say that she was one of the motivations for you to get involved in this first place? I think you've you've been at a KF twice. Right? You started there earlier in your career, and then again, later on?

Mike Spigler  23:07  
Yeah. So she was  not the impetus for coming the first time first time was just kind of happenstance I ended up coming here. I was here for about five years and left for a couple other opportunities in the nonprofit space and was in mental health and in food allergies for a while, but she was certainly one of the reasons for coming back. And you know, I've been here seven years, this, this go around as well. And I've really enjoyed my position here. And it's such a great place to work. And it's also a great mission that we have. And like I said, just seeing the the wide range of, you know, knowing that every day we come in and we help her help prevent kidney disease. But for those that are already on dialysis, knowing what we do to get patients transplanted, it really is a very fulfilling place to work. Yeah,

Patrick Short  23:48  
absolutely. I'd love to hear your thoughts on any new technologies that you're excited about whether it's testing at the early stages. So you know, transplantation, you probably, you know, think about all sorts of things. And I know your team's funding a lot of research. What what are you excited about? Are there one or two things that you think are really going to make an impact in the next five or 10 years?

Mike Spigler  24:09  
Well, I mean, I'll start with the 10 year piece. I mean, I would I am super hopeful that the artificial kidney will will come to fruition at some point, you know, they've got most of the technology down there trying to get some of the you know, the the kidney cells that would get the toxins out of the blood, if they can get that fixed. I mean, that will go a long way to keeping patients off of dialysis. The scale of that problem look like how many patients go on dialysis, that could benefit from a kidney transplant? Yeah, I mean, I think we have something like 600,000 patients in kidney failure in the US right now. So that's, that's a huge piece. I mean, not everyone will qualify for it for the artificial kidney because of you know, surgery risks and things like that. But most may mean who knows what the scale of to your point, though, what I don't know. When that comes to market. What's the scaling look like? I don't know that but that's definitely on the on the long term end, I think on the on end, I mean, I mentioned some of the STL T twos, GLP ones for patients with diabetic kidney disease, I mean, diabetic kidney diseases, you know, that's 40% plus of patients on kidney failure, if we can manage that aspect, I mean, maybe we can prevent patients from getting them a fair amount from getting on dialysis in the first place. But another thing we did with that survey that I mentioned is, we asked primary, there was a significant number of primary care doctors, we asked them opening the question just lists some of the new innovations in the kidney disease space, and they were not, they were not mentioned very often. So there's still a lot of work to be done to raise awareness about that. And I really think they're a game changer, that that class of drugs just on the front end, but I mean, for rare disease, also, there's just so many innovations happening right now. I mean, when I worked here, the first time, the early 2000s, I was kind of an entry level position here, I was answering that the helpline phone calls and patients calling in and just think back people calling him, you know, I Gan or something like that. And I would say, well, here's what it is, there's not really a cure for it or anything. So talk to your doctor, and now there's a medication for it. And I think there's something like 50 different trials going on for IBM alone. So I think the you know, again, to circle all the way back, you know, to the to the work you guys are doing to it's in this genetic realm, there are answers and solutions for patients now. So you know, PKD is another one, you have polycystic kidney disease, that might have been something where, you know, you have a family member that had it previously. And I know people that have had PKD, like I don't want to get tested. But the fear doesn't have to be that there is a there's a treatment for it now. So these innovations across the board from you know, they're kind of, quote unquote, run of the mill diabetic kidney disease, to rare disease, to eventual, you know, eventual, you know, solutions for things like dialysis, artificial kidney, and it's the vast difference in the early 2000s. Coming in here now is just unbelievable.

Patrick Short  26:51  
It's great. And it's very optimistic note to end on and there's one other things that I wanted to flag up, which is I think you all are hosting kidney Action Week in in early June, right, June 6 to 10th. For people who want to either take part, join one of your events or help out in some way what what should they do? And maybe you could tell us a little bit about it. Yeah,

Mike Spigler  27:11  
thank you for bringing that up. So the first thing I would recommend is go to kidney action. week.org. You do have the dates right. It's June 6 through the 10th. It is completely free for patients was free for anyone but you know, it's aimed at patients and caregivers, you can pre register kidney action week.org. If you follow us on Facebook or on YouTube, they're also going to be simulcast live on both of those platforms as well. We had over 7500 unique patient participants last year's event, I think it's gonna be even higher this year, we have 20 different sessions that are full sessions and also another 15 of things like cooking demonstrations, and fitness demonstrations and things like that. So there are lots of great information no matter where you are. So if you're in chronic kidney disease, you know, we have we have, you know, things that keep you off of dialysis and, and, and from kidney failure. If you have a rare disease, we have a session on it. Again, we have a session on polycystic kidney disease, we have a session on chronic stone formers. So for some of the stone, kidney stone rare diseases, we have information on that. If you're on dialysis, we got information on home dialysis, if you're trying to get a kidney transplant list, we've got a whole session on that. So really a really rich, free programme. So it's kidney action week.org. We'd love to have everyone join that.

Patrick Short  28:22  
I checked out the website. And you all have I mean, you must spend, you must spend six months to a year planning this thing out because you've got an incredible list of speakers and a lot of really creative sessions as well as this one of the big things that your team focuses on.

Mike Spigler  28:37  
Yeah, you know, this, this came out of the pandemic, one of the only positives of a combat pandemic is that, you know, we used to go out in the community and do these events in person. They're called Kitchen, kidney action days and underserved population or communities. And we would do, you know, cooking demonstrations and screenings and exercise demos live that obviously did not survive the pandemic. So we moved to kind of online and now we've, it's not just kind of prevention, it's everything. You're right, it takes about nine months to pull it off. And we're moving it next year into March. So what that means is the second this one is over, we already started planning for the next years, but it'll live in March and perpetuity moving forward for kidney month.

Patrick Short  29:17  
Great. And the other thing I wanted to suggest that people follow you on Twitter if they're interested, I think you're at Michael Spiegler. I had a lot of fun preparing for the episode. Scrolling back through I think my favourite was seeing you as Ted last. So for Halloween. Yeah. Roll back a little ways.

Mike Spigler  29:35  
Yeah, I'm not as active as I probably should be my position. But I try to post some things on there when I can. So a little bit of a peek behind the curtain there.

Patrick Short  29:44  
I think it's great. And I think Ted is a leadership inspiration to us all as well. Thank you again. I really appreciate it. I really enjoyed the discussion. Thanks for the amazing work you and the rest of the team are doing.

Mike Spigler  29:58  
Thank you, Patrick. I really appreciate it. Thanks for all work you're doing to bring innovation to the space.

Patrick Short  30:02  
Thanks everybody for listening and as always, please share with a friend. If you liked the episode, leave us a review on your favourite podcast player to help other people find us. And as always get in touch if you have any guest ideas, suggestions on how we can improve. Thanks again and we'll see you next time.