Diabetic kidney disease and type 2 diabetes: best practice – InSight+

CHRONIC Kidney Disease (CKD) is a common and potentially fatal condition that affects about 238,000 Australians† Type 2 diabetes is a leading cause of CKD worldwide† The prevalence of CKD in patients with type 2 diabetes is twice as high as in patients without type 2 diabetes

As the incidence of type 2 diabetes continues to increase, worldwide and inside Australiaso is the incidence of diabetes-associated CKDalso known as diabetic kidney disease (DKD).

GPs play a fundamental role in identifying patients with type 2 diabetes who may have DKD and then ensuring that they are treated with drugs that have proven kidney-protective effects. Access to new treatments with minimal side effects and a high degree of tolerability will give GPs more options to manage the progression of DKD.

Current fundamental principles to slow the progression of DKD include tight metabolic and blood pressure control and the use of renin-angiotensin system (RAS) blockers. However, many people with type 2 diabetes and DKD can still affected with further decline in renal function and an increased risk of death, not only from kidney damage but also from cardiovascular disease. Patients with type 2 diabetes are three times more likely to die from cardiovascular causes than from diabetes alone† Therefore, there is a great unmet need for early intervention to prevent renal failure in people with type 2 diabetes.

All of these factors indicate an immediate need for early diagnosis, intervention, and disease-specific treatment options for patients with DKD. This article highlights methods to aid early diagnosis of DKD, as well as management strategies to reduce the risk of DKD progression after diagnosis.

Early diagnosis and screening

Early stage DKD is usually a silent disease, with minimal clinical manifestations until the patient has progressed to advanced stage of renal disease, possibly to the point of requiring renal replacement therapy.

It is therefore crucial to proactively screen for markers of renal disease in high-risk patients with type 2 diabetes for early diagnosis. This includes:

  • Blood tests, routine for patients with type 2 diabetes, are an easy way to measure estimated glomerular filtration rate (eGFR), an important marker of kidney function. a value of less than 60ml/min/1.73m2 gives possible DKD . at
  • Patients with type 2 diabetes may also have an annual urine sample taken to measure the albumin to creatinine ratio. A ratio greater than 2.5 mg/mmol in males or 3.5 mg/mmol in females is a possible marker of kidney damage

It should be noted that a a high albumin/creatinine ratio can also be an indication of cardiovascular disease.

Confirmed findings of a eGFR of less than 60 ml/min/1.73 m2 and/or the presence of albuminuria are required for the diagnosis and staging of CKD in patients with type 2 diabetes

Special care should be taken to exclude non-diabetic causes of CKD. Patients with rapidly increasing albuminuria or decreasing eGFR may be eligible for referral to a nephrologist. An eGFR threshold of less than 30 ml/min/1.73 m . to achieve2 may also be a nephrological referral trigger.

Pharmacological intervention

Currently, the backbone of pharmacologic interventions for DKD in patients with type 2 diabetes involves the use of RAS-blocking drugsbecause this system is usually upregulated in type 2 diabetes.

Sodium glucose cotransporter-2 (SGLT2) inhibitors are also: now recommended as a treatment for patients with DKDThis class of medication works by blocking the reabsorption of glucose in the renal tubules† These inhibitors not only lower blood glucose levels by inducing glycosuria, but also act as diuretics, lowering blood pressure (possibly in the glomerulus) to protect against the progression of DKD.

There has been interest for some time in using aldosterone blockers (promoted by RAS activation) to slow the progression of DKD. Aldosterone binds to the mineralocorticoid receptor and overactivation of this receptor is another major driver of DKD progression. However, the side effects and lack of tolerability of existing mineralocorticoid receptor antagonists are: well recognized in clinical practice† Finerenone is the first-in-class non-steroidal mineralocorticoid receptor modulating option approved for DKD in type 2 diabetes in Australia (here and hereRecent Major Clinical Trials have shown that the use of finerenone, in addition to normal standards of care, including RAS blockers, can significantly slow the progression of kidney disease and reduce kidney-related deaths and cardiovascular events. In these studies, the incidence of treatment-emergent adverse events was balanced between finerenone and placebo-treated patients.

Finerenone is indicated by the Therapeutic Goods Administration to slow the progressive decline of renal function in adults with CKD associated with type 2 diabetes (with albuminuria), in addition to standard treatment (the medication is not currently included in the Pharmaceutical Benefits Schedule). Finerenone will be available as a tablet of 10 mg or 20 mg once daily, with dosing based on eGFR and potassium thresholds. Finerenone has yet to be included in Australia’s clinical guidelines.

Lifestyle and metabolic management

In combination with pharmacological intervention, attention to lifestyle factors remains very beneficial for slowing the progression of kidney disease. These factors include maintaining a healthy weight, following a regular exercise program, and limiting salt intake.

High blood pressure is a known cause of chronic kidney disease, including DKD, and tight blood pressure control is the basis for preventing decline in kidney function in people with DKD. Kidney dysfunction is also a major risk factor for cardiovascular disease, so it’s equally important to follow aggressive treatment for cardiovascular risk factors, including maintain lipid profile control through the use of statins† Studies have shown that maintaining good blood metabolism and pressure control slows the progression of DKD up to 50%

As the most frequent point of contact for patients with type 2 diabetes, GPs are well placed to build meaningful relationships with patients and are thus in the best position to help patients develop and maintain good risk factor management.

With the growing burden of DKD in patients with type 2 diabetes, primary care physicians are in a unique position to support high-risk patients and identify early signs of renal disease progression and help adjust risk factors. With major breakthroughs and advances in new renal protective drugs, GPs are better equipped than ever to prevent the progression of DKD and prolong a better quality of life for their patients.

Richard MacIsaac is Director of Endocrinology and Diabetes at St Vincent’s Hospital, Melbourne and Professorial Fellow at the University of Melbourne. He is also Senior Principal Research Associate at St Vincent’s Institute of Medical Research, Honorary Clinical Research Fellow at the Bionics Institute of Australia and Diabetic Kidney Disease co-stream leader for the Australian Center for Accelerating Diabetes Innovations Research Center (ACADI), University of Melbourne. He has published more than 280 research papers.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MYA or InSight+ unless so stated.

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