Prevention and management
Controlling hyperglycemia, hypertension, hypercholesterolemia, and albuminuria in patients with DM may reduce the risk for, or slow the progression of, CKD. Results from the ADVANCE and Kumamoto studies showed that tight glycemic control to achieve HbA1c <6.5% decreased the risk for worsening nephropathy.36,37 The Appropriate Blood Pressure Control in Diabetes (ABCD) study showed that lowering BP in patients with T2DM and hypertension stabilized renal function.38 The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study showed that decreasing cholesterol in patients with T2DM slowed the progression of albuminuria over five years of follow-up.39 Finally, individuals found to have other modifiable risk factors (e.g., obesity, smoking) should be advised to follow a risk factor reduction program.7
Some angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) can help decrease proteinuria,40 and treatment with an ARB has resulted in a 23% reduction in the risk for ESRD compared with alternative treatments, but this reduction was not statistically significant.41 Some ACEIs and ARBs are approved for slowing the development of, or preventing, proteinuria and renal deterioration, while others are not.
Integrated therapy aimed at two or more of the above CKD risk factors has at least additive effects on risk reduction. The ADVANCE trial indicated that decreasing HbA1c and BP had additive effects in decreasing the risks for new or worsening nephropathy.42 The Steno-2 trial showed that intervention aimed at decreasing hyperglycemia, high BP, dyslipidemia, and microalbuminuria was significantly superior to conventional treatment in decreasing the risk for nephropathy in patients with DM.43
There is a DM epidemic in the United States, and the number of people with this disease is expected to exceed 44 million over the next 25 years. This increase will likely result in a corresponding rise in complications of T2DM, such as CHD and CKD. Approximately 40% of patients who have T2DM develop CKD/RI, and T2DM is the leading cause of ESRD in the United States. Risk factors for CKD/RI in patients with T2DM include inadequate glycemic control, albuminuria, hypertension, hyperlipidemia, and smoking. CKD/RI in patients with T2DM increases morbidity and mortality due to CV and renal events. Thus, physicians and patients need to be aware of CKD/RI. The early screening and identification of patients with, or at risk for developing, CKD using the ACR in a spot urine sample and eGFR affords the opportunity for treatment to prevent or delay the progression of CKD/RI. The presence of comorbidities and complications in a patient with T2DM not only increases the risk for CVD but increases the risk for hypoglycemia and complicates the selection of antidiabetes agents.
Dr. Thomas is the clinical care coordinator of the diabetes program at Montefiore Medical Center, Bronx, N.Y. Dr. Kodack is vice president, medical, BlueSpark Healthcare Communications LLC, Basking Ridge, N.J., which was contracted by Boehringer Ingelheim Pharmaceuticals, Inc. to provide editorial and authorship assistance toward the preparation of the manuscript.
This promotional article was funded by Boehringer Ingelheim Pharmaceuticals, Inc., and Eli Lilly and Company. Dr. Thomas has disclosed no potential conflicts of interest. Dr. Kodack is an employee of BlueSpark Healthcare Communications LLC.
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