Increased use of screening and medication for diabetes-related chronic kidney disease (CKD) is crucial to mitigate risks to patients and reduce unnecessary burdens on healthcare resources.
A recent report on the unmet needs of patients with diabetes and CKD, published by Cleveland Clinic physicians in the Journal of Diabetes and its Complications , identifies opportunities to significantly improve care for patients at high risk of developing cardiovascular disease and end-stage renal disease (ESKD). The authors reviewed data from the Cleveland Clinic electronic medical record from 2005 to 2019. The patient group was divided into three cohorts: those with CKD, those with type 2 diabetes (T2D), and those with CKD and T2D. The goal was to better understand the uptake of screening tests and the use of appropriate medical interventions.
"We now have multiple medications to help reduce the risk of CKD progression in patients with and without type 2 diabetes," says endocrinologist Kevin M. Pantalone, Director of the Diabetes Initiative in the Department of Endocrinology, Diabetes and Metabolism. "But to identify these patients and treat them, you have to make sure you do the right screening."
Key results:
- Although American Diabetes Association guidelines recommend annual urine protein screening (by obtaining a urine albumin/Cr ratio, commonly known as UACR) for patients in all three disease categories, most had not been screened.
- A low percentage of patients were taking ACE inhibitors (ACE inhibitors), angiotensin II receptor blockers (ARBs), or sodium glucose cotransporter 2 inhibitors (SLGT-2i), which may improve kidney-related outcomes.
- More than half of patients with CKD alone (52.9%) or T2D and CKD (54.9%) had been hospitalized, compared with 41.8% of patients with T2D alone.
"When we looked at patients receiving therapies known to help protect kidney function (ARBs and ACEIs), we saw that while many patients received them, there were many patients who probably should have received them and did not," he says . Dr. Pants alone. “These medications have been around for many years and are inexpensive. Therefore, it cannot be argued that the cost of medications is the barrier.”
However, one barrier is the underuse of testing to identify patients who might benefit. In 2019, the percentages of patients who underwent urine protein testing were 7.6 for those with CKD; 30.2 for those with CKD and T2D; and 20.1 for those with type 2 diabetes.
While researchers did not determine the reasons for the low uptake of urine protein screening tests, Dr. Pantalone says it is likely due to a combination of doctors not ordering the tests and patients not complying. requested orders.
“There is no reason not to screen your patients for type 2 diabetes with or without CKD. Annual urine protein testing is considered a standard of care intervention,” she says.
When it comes to protecting the kidneys from diabetes-related damage, the stakes are high.
" Dialysis carries a very high burden of morbidity and mortality for patients," says Dr. Pantalone. “And from a system perspective, dialysis patients require more resources and interventions. “So if we can identify a group of patients earlier in the disease course and implement interventions to reduce the risk of progression, we will eventually be able to reduce the number of patients who end up with ESKD.”
Avoiding ESKD is not the only goal. Chronic kidney disease in patients who have lower estimated glomerular filtration rates (eGFR) have a significantly high cardiovascular risk. Patients with CKD are five times more likely to die from cardiovascular disease than to develop ESKD.
“Having CKD carries a risk of suffering adverse cardiovascular events equivalent to that of someone who has already had a diagnosis of cardiovascular disease, because their risk of dying from a cardiovascular event is very high,” he says. "Therefore, identifying these patients through screening and providing appropriate therapeutic interventions is important from the point of view of reducing the risk of CKD progression as well as the risk of cardiovascular events."
Thinking in the future
Researchers are also conducting a longitudinal analysis to identify how CKD patients progress over time and evaluate ways in which acute events, such as hospitalizations, may accelerate disease worsening.
“We know that when patients are hospitalized, they generally do not recover to the initial level of their illness. They have a new baseline,” says Dr. Pantalone. "That’s why it will be important to follow patients, see how they change, and develop algorithms to predict who is at highest risk of progression."
More information is also needed to establish why patients who should undergo urine protein assessments do not undergo testing.
"We want to look at patient-provider relationships where we have inertia and see who is driving it," Dr. Pantalone says. “We have a diabetes health maintenance component in our electronic health record. It’s obvious to anyone who’s dialed in: it should be done every year along with a dilated eye exam. And in many cases, it is ordered, but it is simply not completed .”
For suppliers
For providers who want to make the most of opportunities for CKD patients, Dr. Pantalone points out the importance of getting the data right.
"We do a good job of monitoring GFR because we order routine blood tests containing serum creatinine and use formulas to calculate the patient’s estimated GFR," he says. “But eGFR and urine protein level are needed to adequately stratify a patient’s risk of CKD progression. “A patient may have stage three CKD and be at much higher risk of progressing if she has a reduced GFR in addition to significant protein loss in the urine.”
Additionally, he says, the job of improving drug discovery and uptake falls largely on primary care providers. "It serves more than 90% of patients with type 2 diabetes," says Dr. Pantalone. "We need to work with our primary care providers to develop strategies that improve the likelihood that annual UACR testing will be obtained and, if the result is abnormal, acted upon."
Final message Overall, our data confirmed that patients with CKD, type 2 diabetes, or both CKD and type 2 diabetes place a large burden on the healthcare and economic system, as seen in the high rate of hospital admissions and emergency department visits. Addressing unmet needs and optimizing treatment for these patients will be critical to reducing disease progression and cardiovascular and end-stage renal disease resulting from these widespread disease states. As new therapies are introduced to the market, providers will be better equipped than ever and tasked with identifying and treating CKD at earlier stages in patients with type 2 diabetes to prevent and delay disease progression, as well as the traditional treatment pillars that optimize blood pressure and glycemic control and use of ACEI/ARBs. |
