麻豆传媒

ORLANDO -- Proper treatment and prevention strategies are required to prevent the progression of chronic kidney disease (CKD) in patients with diabetes, a specialist said here.

Comorbidity risk is particularly high among people with type 1 and type 2 diabetes, with around 30% of patients expected to develop some form of kidney disease with around 10 to 15% developing end stage renal disease requiring kidney transplant, according to Carlos Bejar, MD, of Nova Southeastern University and the University of Miami, during an oral session at the National Kidney Foundation's spring clinical meeting.

Diabetes-related issues may contribute to as much as half of patients currently receiving dialysis, Bejar said. However, there is a notable gap in the current literature, and he pointed to "ongoing investigation" into the condition's pathogenesis, expressing his hopes for a genome-wide association study to be published in the near future.

In order to mitigate risks, he suggests all primary care providers annually screen patients with type 2 diabetes for diabetic kidney disease, as recommended by the current American Diabetes Association's . Diabetic retinopathy poses another significant risk, particularly among patients with type 1 diabetes, as an estimated 90 to 95% of these patients will develop the condition, while 60% to 65% of type 2 diabetics may develop.

In terms of preventing the progression of nephropathy among diabetic patients, glucose control is the key starting point, Bejar said. Some previous studies, such as the DCCT trial, suggested benefits to tight glycemic control (target HbA1c <6.05%) versus conventional care (HbA1c 8%-9%) among type 1 diabetics in terms of renal improvements with microalbuminuria, proteinuria, and small reduction in eGFR.

Benefit from intensive control is less clear among type 2 diabetics, owing to the lack of longer-term studies; Bejar noted that most diabetics do not develop kidney disease until ten to fifteen years following initial diagnosis. However, he advised more lenient glucose control in order to mitigate the comorbidity and mortality rates, suggesting a more "multifactorial approach" to treatment, particularly regarding cardiovascular outcomes among sicker patients.

As to the effects of lowering lipids in the diabetic population on renal outcomes, "The verdict is not out yet," Bejar added. He said most patients with diabetes should receive a statin since they will also have metabolic syndrome and significant cardiovascular risk.

Weight loss and smoking cessation are highly recommended for all patients with diabetes to prevent nephropathy, Bejar said, noting the current ADA guidelines call for sending all patients with diabetes to a self management education and support group (A-level recommendation), with proven benefit to patient care and cost outcomes. Modifications to diet, exercise, and blood pressure control are known to improve outcomes.

In terms of hypertension, it is a known risk factor for the progression of diabetic kidney disease. Type 2 diabetics will most likely have high blood pressure at the time of diabetes diagnosis, while type 1 diabetics might not develop it until they develop overt nephropathy around a decade later. The current ADA guidelines recommend people with diabetes have a target blood pressure of less than 140/90, although those at high risk for cardiovascular events should have a tighter target of 130/80 to mitigate risk. In addition to lifestyle modification, those in a range above 140/90 and less than 160/100 "should leave your office with one agent," Bejar recommended, while those with higher values probably need two agents.

For the future of diabetes management for patients with CKD, Bejar called for more research surrounding biomarkers, particularly for glomerular, tubular, and inflammation biomarkers. He said he expects vascular endothelial growth factor B (VEGF-B) will show promise in this regard. In the meantime, current technology is the key to prevention, applauding smartphones and fitness trackers as aids for patients seeking lifestyle modifications.

Find the American Association of Clinical Endocrinologists comprehensive type 2 diabetes management algorithm , including recommendations for patients with CKD.

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