Challenges in the Prevention and Management of Diabetic Kidney Diseases

Abstract

“If you define the problem correctly, you almost have the solution” Steve Jobs Diabetic kidney disease (DKD) is one of the common complications of diabetes mellitus, which substantially decreases the quality of life and increases the risk of premature mortality (1). Although it is the most common cause of end-stage renal disease (ESRD) (2), the mortality is mostly due to cardiovascular diseases and therefore DKD is regarded as a major cardiovascular risk factor (3, 4). Due to its chronic and slowly progressing nature, DKD is generally diagnosed by screening tests showing albuminuria or low eGFR, or both in subjects with diabetes. Up to one-third of patients with type 1 diabetes (T1DM) (5–7)and nearly half of patients with type 2 diabetes (T2DM) have DKD (6, 8–10). Yet, fewer of them receive optimal care to prevent DKD progression and avoid the cardiovascular and renal endpoints (11). Although the term “Diabetic Nephropathy” is used interchangeably with DKD, the former more specifically describes the histological alterations such as glomerular basement membrane thickening, or mesangial proliferation observed in subjects with T1DM, which predominantly occurs due to chronic hyperglycemia (12). However, DKD observed in subjects with T2DM involves Diabetic Nephropathy but also the alterations seen due to other causes such as aging, hypertension, or obesity. This is probably the reason for observing DKD more frequently in subjects with T2DM. As multiple risk factors play role in the pathogenesis of DKD and its cardiovascular consequences, intensive glucose control is not enough to prevent renal and cardiovascular endpoints in DKD (13). Therefore, chronic risk management is essential along with good glycemic regulation, to prevent the occurrence and progression of DKD and to reduce the premature cardiovascular events in patients with diabetes (14–17). Unfortunately, the global data shows that people with diabetes are not under good glycemic control, nor they attain the metabolic targets (18–20). We have recently performed a nationwide survey in Turkey (6). Our findings replicate the global data and show that less than half of patients with T2DM reach the target HBA1c levels and only 10% of them simultaneously attain the targets for blood glucose, blood pressure, LDL Cholesterol. The situation is even worse in patients with T1DM, with less than 5% attainment rates of the three targets. When we also consider smoking cessation and regular exercise, only 1.5% of patients with both types of diabetes reach all these targets simultaneously (6). There is also significant inertia in establishing appropriate targets and optimizing treatment to achieve treatment goals (11, 21, 22). To solve this problem, we should better understand the reasons behind it. There are significant problems in the current practice of diabetes management involving the screening of DKD, optimization of therapy, making timely referrals, and managing risk factors and complications (23). The failure to establish appropriate targets and modify treatment to attain the goals, namely “clinical inertia” is responsible for the increased complications and health care burden (11, 24). Some of the main barriers to optimal patient care are touched upon below: The capacity of patients to obtain, process, and understand basic health information, so-called “health literacy”, is one of the key factors in the appropriate management of patients with diabetes (25, 26). With diabetes in general have unhealthy lifestyles, which are not easy to modify (27). Older adults and patients with lower socio-economic status are more likely to have diabetes (28, 29) and less likely to follow the recommendations of their physicians (30). Many people with diabetes are not intended to use insulin due to the fear of hypoglycemia or weight gain or becoming dependent on insulin treatment (31, 32). Negative media coverage is also a significant reason for the incompliance especially of statins (22, 33, 34). Polypharmacy is also a major obstacle in reducing patient compliance and the attainment of targets (35). Diabetes is so common that most of the patients are inevitably followed up in primary or secondary care facilities. Physicians working in these services may not have enough knowledge or experience in setting appropriate targets or implementing medications or modifying treatment while managing patients with diabetes (11). Low GFR is often not considered for adjusting the dose of antidiabetic drugs that are contraindicated in DKD (36). Also, physicians may not care enough to modify the doses of antidiabetic and antihypertensive medications during the follow-up of patients with diabetes (21). Lack of enough time to communicate with the patients and lack of supporting health staff are always the leading barriers in the crowded outpatient units (23). There are a multitude of diabetes guidelines to fill the knowledge gap in the field (14–17). However, physicians working in crowded outpatient units are bewildered by these long, complicated, and hard-to-read documents. They need concise, and problem-oriented algorithms to help them find their way. High quality and sustainable health care depend on well-adjusted infrastructures of the healthcare system, software for the electronic data recording and follow-up, wide-ranging health insurance coverage, and a reasonable reimbursement strategy (37). There are huge differences between the costs of new and old antihyperglycemic medications, which is not easy to be afforded by the patients (38). All these factors significantly differ between different countries. Doctors lack enough time to spend with their patients. The centers may not have enough capacity for necessary laboratory tests and many physicians do not have a consultation link for further management of the complications of their patients. We need to cross all these barriers to optimize...