As the incidence and prevalence of type 2 diabetes have grown, there has also been an increase in the number of people developing diabetic kidney disease (DKD) and end-stage renal disease (ESRD). “Diabetes is the leading cause of ESRD, accounting for almost 50% of cases,” says Mark E. Molitch, MD. Incidence rates for ESRD have stabilized over the past few years, but differences remain among high-risk subgroups, including middle-aged African Americans, Native Americans, and Hispanics. The healthcare disparities may be partially due to increasing rates of obesity and diabetes among younger people from these populations.
Research has shown that the overall costs of care for people with DKD are extraordinarily high, due in large part to the strong relationship of DKD with cardiovascular disease (CVD) and the development of ESRD. In 2011, overall Medicare expenditures for diabetes and chronic kidney disease (CKD) in people aged 65 and older were approximately $25 billion. As patients transition to ESRD, studies have shown that the per-person per-year costs are $20,000 for those covered by Medicare and $40,000 for patients younger than 65. Importantly, much of the excess CVD resulting from diabetes is accounted for by people with DKD.
Addressing Vital Issues
In 2014, the Consensus Conference on Chronic Kidney Disease and Diabetes was convened by the American Diabetes Association in collaboration with the American Society of Nephrology and the National Kidney Foundation because of the high human and societal costs associated with DKD. “The consensus report addresses vital issues regarding patient care,” says Dr. Molitch, who co-chaired the consensus group. It highlights current practices, gaps in knowledge, and new directions for improving outcomes. The report is designed to guide advances in patient care and generate new knowledge that can improve the lives of people with DKD.
Strive for Early Detection
According to the consensus report, the identification of DKD depends upon screening for increased albuminuria and low estimated glomerular filtration rate, but both measures are imprecise. This highlights the need for better identification methods, especially for those at high risk of DKD complications. The report recommends self-monitoring of blood glucose to achieve glycemic goals and mitigate risks for hypoglycemia. In older adults with long-standing diabetes and CKD, greater efforts will be needed to avoid hypoglycemia, and less stringent A1C targets are recommended.
“Early identification of DKD is important so that it can be managed as early as possible,” says Dr. Molitch. “It’s also important to consider the causes of DKD. If findings are atypical of DKD, it’s possible that the patient has another type of kidney disease,” he says. The consensus report outlines several cir-cumstances in which other causes of CKD should be considered (Table 1).
Prevention Is Key
Prevention is the cornerstone for reducing the burden of DKD, according to Dr. Molitch. “Glycemic control is at the core of good diabetes care and has been shown to delay and/or prevent the onset as well as progression of DKD,” he says. “Blood pressure control and use of drugs that block the renin-angiotensin-aldosterone system are also important in delaying progression of DKD. Furthermore, prevention of CVD is paramount and centers on managing cholesterol and blood pressure.” The consensus report provides recommendations for managing multiple risk factors in DKD, including hyperlipidemia, hypertension, and hyperglycemia (Table 2).
More information on risk factors that are unique to patients with DKD is needed in order to improve risk stratification and treatment strategies, according to the consensus report. In addition, it is essential to increase awareness surrounding the safety and efficacy of new therapeutic approaches. Safety must also be carefully evaluated when FDA-approved drugs are used for new indications or in combination with other therapies. “The key is to use established and new therapies at the earliest possible stage to prevent complications in the future.”
The consensus report offers several strategies that may be of benefit when managing patients at high risk for DKD. These include using medical home models, integrating multiple risk factor management, and adhering to patient-centered care. A team-based approach to care—one that includes healthcare professionals from various disciplines—and effective communication are other important requirements to successfully manage DKD.
“Although we have some treatments that can benefit patients with DKD, there is still an urgent need for novel therapies to improve outcomes,” says Dr. Molitch. “More research is needed on these emerging treatments. We also need studies to ensure that we’re optimizing the delivery of care to these patients. The hope is that this consensus report will lead the way, filling our gaps in knowledge and advancing care for people with DKD.”
Readings & Resources (click to view)
Tuttle KR, Bakris GL, Bilous RW, et al. Diabetic kidney disease: a report from an ADA consensus conference. Diabetes Care. 2014;37:2864-2883. Available at: http://care.diabetesjournals.org/content/37/10/2864.abstract.
de Boer IH, Rue TC, Hall YN, Heagerty PJ, Weiss NS, Himmelfarb J. Temporal trends in the prevalence of diabetic kidney disease in the United States. JAMA. 2011;305:2532-2539.
Bakris GL, Molitch M. Microalbuminuria as a risk predictor in diabetes: the continuing saga. Diabetes Care. 2014;37:867-875.
Taler SJ, Agarwal R, Bakris GL, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for management of blood pressure in CKD. Am J Kidney Dis. 2013;62:201-213.