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Better Prevention/Treatment for Diabetic Kidney Disease in T2D

Mar 30, 2021
 
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Jonnessia Winslow, PharmD Candidate, South College School of Pharmacy

Are you doing everything you can to ensure your patient has the best quality of life possible with type 2 diabetes? Exploring better strategies for prevention and treatment of diabetic kidney disease.

It’s often said that with age comes the highly desired quality of wisdom. Still, in that same world, age-related metabolic and renal changes predispose older adults to an increased risk of diabetes mellitus and diabetic kidney disease. The prevalence of the aging population continues to grow with increased life expectancy, and so does the likelihood of diabetic kidney disease. The global prevalence of diabetes mellitus is expected to reach 10% in 2045. Almost half the population with diabetes is more than 65 years old, with a peak prevalence of 75-79. 

 

A healthy lifestyle and control of cardiovascular risk factors such as hyperglycemia, hypertension, and dyslipidemia should be the top priority to manage this condition. Keep in mind many patients with diabetic kidney disease progress to renal failure accompanied by adverse cardiac outcomes. The progression of diabetes is associated with long-term microvascular complications, including diabetic nephropathy. The main features of diabetic nephropathy are albuminuria, hypertension, and low estimated glomerular filtration rate. Diabetic kidney disease accounts for most of the CKD cases globally and is associated with a gradual decline in kidney function. 

With that being said, older age increasing diabetes prevalence, and the prevalence of DKD that progresses to CKD and ESRD, also increase the morbidity and mortality in older people, putting an enormous financial cost on healthcare systems. It’s essential to diagnose and promptly screen so effective interventions can be made to decrease the prevalence of DKD. 

Aging brings about renal structural and functional changes. Renal regulation of extracellular body fluid volume may not be affected during a healthy state, but the compensatory mechanism to maintain volume composition during acute illness is impaired. The renal system is at a greater risk of failing with old age. Body composition and pancreatic changes lead to increased insulin resistance and reduced insulin secretion, therefore developing diabetes. Lack of physical activity leads to a reduction in muscle mass. Insulin resistance increases due to it being the primary site of glucose consumption. 

Type 2 diabetes renal pathologic changes are similar to type 1 diabetes but less predictably associated with clinical presentations. Management is a crucial aspect. The first-morning urine sample, eGFR, and serum creatinine values are required for screening and diagnosis. As DKD increases CKD risk, progression to ESRD, cardiovascular events, and mortality, early screening and timely interventions are mandatory. Additionally, the prevalence of CKD in patients with diabetes increases further when cardiovascular disease co-exists, suggesting that interventions to reduce cardiovascular risk factors are essential to reduce the risk of the progression of DKD to CKD and ESRD. Interventions include adopting a healthy lifestyle and pharmacologic control of hyperglycemia, hypertension, and dyslipidemia. However, because of the heterogeneous nature of older people with type 2 diabetes, factors such as comorbidity, frailty, and functional level should be considered in the management plan 

Aging is associated with metabolic and renal changes that predispose older people to an increased risk of diabetes and DKD. As the aging population is increasing, the prevalence of DKD is likely to increase, leading to significant adverse outcomes and costs to healthcare systems. Management of the traditional cardiovascular risk factors such as promoting a healthy lifestyle and controlling glycemia, hypertension, and dyslipidemia will slow down the progression of DKD and improve outcomes. However, older people are susceptible to the side effects of pharmacologic interventions; therefore, strict targets will be suitable for fit patients, while relaxed goals are reasonable for more frail individuals. There is still room for future research to investigate methods of early diagnosis and develop novel therapeutic interventions. 

Practice Pearls: 

  • A healthy lifestyle and control of cardiovascular risk factors such as hyperglycemia, hypertension, and dyslipidemia should be a top priority to manage this condition.  
  • The global prevalence of diabetes mellitus is expected to reach 10% in 2045. Almost half the population with diabetes are more than 65 years old, with a peak prevalence at 75-79 years of age. 
  • Older people are susceptible to the side effects of pharmacologic interventions; therefore, strict targets will be suitable for fit patients, while relaxed goals are reasonable for more frail individuals. 

 

References for “Better Prevention / Treatment for Diabetic Kidney Disease in T2D”:

Salvatore De Cosmo, et al. Kidney dysfunction and related cardiovascular risk factors among patients with type 2 diabetes 

Bruce M Robinson, et al., Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and hemodialysis practices 

 

Jonnessia Winslow, PharmD Candidate, South College School of Pharmacy