An excerpt from Dr. Ndidiamaka Obadan’s interview with Allie Strickler, a health and technology writer from OneDrop.
Q: In January of this year, the ADA added a new section to its 2022 Standard of Care guidelines directed at the prevention and management of chronic kidney disease and related complications in people living with diabetes. Please explain what underlies the link between kidney disease and diabetes (including differences between prevalence in those with T1 vs. T2), and your perspective on these updated treatment guidelines.
A: While Type 1 diabetes is caused by T cell-mediated immune destruction of the pancreatic beta cells which leads to absolute insulin deficiency, type 2 diabetes results from insulin resistance and relative impairment in insulin secretion. Worldwide diabetes is estimated to affect 537 million adults. Type 1 diabetes accounts for 5 to 10% of all cases of diabetes. In the United States, the prevalence of type 2 diabetes among adults ranges from 8.5 to 10.5%.
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Both forms of diabetes can lead to diabetic kidney disease a form of chronic kidney disease (CKD), which is defined as a persistent decline in kidney function for more than three months, as assessed by eGFR estimation. CKD attributed to diabetes also known as diabetic kidney disease, occurs in 20–40% of patients with diabetes.
Although other important mechanisms exist, diabetic kidney disease is a result of long-term metabolic alterations caused by hyperglycemia, hemodynamic mechanisms (glomerular hyperfiltration), and excessive protein excretion. Multiple studies have established the relationship between strict glycemic control in treating either form of diabetes and in reducing the progression of CKD. While the focus of treatment in type 1, is largely insulin replacement, the main goal of treatment for patients with type 2 diabetes is the reversal of insulin resistance.
The most recent standard of care guidelines by the American Diabetes Association recommends screening at least annually, using the urine albumin and estimation of glomerular filtration rate (eGFR), in patients with type 1 diabetes who have a diagnosis duration of greater than five years and in all patients with type 2 diabetes.
They also recommend monitoring diabetic patients with urinary/albumin ratio > 300mg/g creatinine or CKD stage > 3, twice yearly, to guide therapy. The ADA recommendations have similarities with the KDIGO guidelines for the management of diabetes and CKD. These similarities include comprehensive lifestyle therapy, the use of metformin as in first-line therapy, additional inclusion of sodium-glucose 2 co-transporter inhibitors (SGLT2i) for organ protection when CKD is present and self-management education, particularly in patients with urinary/albumin ratio > 300mg/g creatinine
Other recommendations made by the ADA to slow kidney disease progression include the use of renin-angiotensin system (RAS) blockade in patients with hypertension and albuminuria, adjusting treatment according to CKD severity and health system organizations of care, optimizing glucose and blood pressure control while reducing blood pressure variability. They also recommended monitoring of electrolytes while on RAS blockers or diuretics and referring to a nephrologist in patients with GFR < 30m/min, or if with uncertainty about the etiology of kidney disease, in difficult-to-manage situations or for patients with rapid progression of kidney disease.
In my opinion, these recommendations are quite clear and consistent with routine practice and should be adopted as the standard of care. However, using an eGFR cut-off point of greater than or equal to 25 ml/min by the ADA guideline for the initiation of SGLT2i may make it difficult for clinicians to apply this recommendation in the office setting. Using the more Standardized KDIGO staging of eGFR of greater than 30ml/min which translates into CKD stages 1 to 3, makes it easier for physicians and patients to adhere to the recommendations.
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Q: How will someone’s self-care and chronic condition management change if they develop kidney disease in addition to a previous diagnosis of diabetes?
A: When a person develops CKD in addition to diabetes, their chronic condition management and self-care parameters should be modified to reflect the extra layer of complexity, that they now have to contend with. First and foremost, I think they need to invest in themselves and self-management programs. For example, they can invest in education programs including face-to-face, group-based or digital self-management programs, and learn as much as possible about understanding these conditions. Ask questions to their healthcare team, engage family members, and create support systems. They will need a comprehensive care team of health care professionals which will consist of a combination of some or all of the following: a primary care physician, nephrologist, cardiologist, lifestyle medicine specialist, functional medicine specialist, dentist, podiatrist, ophthalmologist, therapist, a nutritionist, and others.
Q: What are some of your general recommendations (nutrition-wise, lifestyle-wise, and/or medication-wise) for someone living with diabetes who wants to prevent kidney disease?
A: General recommendations for people with diabetes to prevent kidney disease include consuming healthy meals rich in fruits and vegetables, modest protein intake (this depends on the stage of kidney disease), avoidance of cigarette smoking, and maintaining a healthy weight as either excessive weight gain or excessive weight loss can lead to worsening for kidney function, overall health and/or worsen diabetes control. Diabetics may be prone to hyperglycemic or hypoglycemic episodes, so it is important to have adequate caloric intake.
With regard to medications, it is crucial for diabetics to have their physician’s input before starting any new medications. Over-the-counter drugs, several medications like herbal, pain, antimicrobials, chemotherapeutic or immunotherapeutic agents, and others, have adverse effects on the kidneys. These medications can worsen kidney function and alter diabetes management. So having a physician and a pharmacist check to make sure there are no drug interactions is a vital step, to prevent the worsening of kidney disease. Another general recommendation is to ensure that other chronic medical conditions like hypertension, heart disease, and autoimmune disease are being taken care of and are under control.
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