Daily Times

Diabetes accounts for more cases of CKD (Chronic kidney disease) than any other disease.

Forty-four out of a hundred kidney disease patients develop the condition secondary to diabetes. Diabetes carries certain inherent characteristics that lead to structural changes in the kidney’s blood vessels, resulting in higher pressure in these vessels that ultimately leads to CKD. The risk of developing kidney disease in diabetic patients runs so high that one in every three diabetics finally gets CKD.

The course of diabetic kidney disease is not very decent, either. Many of these patients end up with the end-stage renal disease, requiring dialysis, the incidence of which is, surprisingly, on the rise, despite all the development in the field of diabetes and kidney disease.

What could be the reason for these pessimistic prevalence scores of diabetic kidney disease and even more pessimistic outcomes?

DELAYED DIAGNOSIS OF DIABETES — we are in the midst of a worsening worldwide diabetic epidemic and Pakistan ranks high among the top contenders in the list of Southeast Asian countries which got the worst hit. Despite all data and dire warnings from WHO, our state hasn’t set forth any strategies to counter this disaster. When I say delayed diagnosis, I am not talking about the delayed diagnosis of just kidney disease; we haven’t yet improved our capabilities to diagnose even diabetes in its early stages. Still stuck in the old mindset, which views diabetes only through the lens of obesity, we dismiss the tell-tale signs of metabolic syndrome and insulin resistance in many lean-looking folks, missing the opportunity to catch many people with diabetes.

DELAYED DIAGNOSIS OF KIDNEY DISEASE — our negligence hardly ends here. Next, we pay no attention to detecting kidney disease in diabetic patients. This diagnosis requires a simple urine test, called urine dipstick, costing only a few Rs 100. If this preliminary test turns out positive, your doctor orders a more specific urine test, called Albumin, Creatine ratio, a test which can give your doctor the exact amount of proteins you are spilling in the urine. Albumin in the urine signals the start of blood vessel damage in the kidney, a hallmark of diabetic kidney disease. Once detected, this marker calls for stricter measures to stem the progression of kidney disease. Since I have started practice in Pakistan a year and a half ago, I have seen only a few patients with diabetes who had their urine checked for albumin-a hard-to-believe level of negligence, considering the fact that guidelines recommend checking albumin in the urine of diabetic patients once a year. For all diabetic patients, it is essential to check, along with other annual check-ups like eye and foot examinations, urine proteins once a year.

POOR MANAGEMENT — the same level of omission is seen in the management plan. Even after a timely diagnosis of diabetes and diabetic kidney disease, we fail to implement the best management. Typically, diabetic kidney disease patients are more likely to have a progression of kidney disease and heart conditions. However, research shows we can mitigate these risk factors by using two classes of drugs. These are ACEIs and ARBs. ACEIs medications usually have -pril at the end of their names, as in Lisinopril and Ramipril. ARBs typically end with -tan, like losartan and Valsartan. By reducing the diabetes-induced high-pressure state in the kidney’s blood vessels, these drugs slow down the ongoing damage, delaying the progression of kidney disease. Such kidney-protective medicines work best when started early in diabetic kidney disease. In these patients, this very medicine also prevents heart-related complications. If you have diabetes, you must ask your doctor why you are not on one of these medications.

NOTE — research showed that using both classes of drugs-ACEIs and ARBs-simultaneously puts you at high risk for adverse effects such as high potassium. Therefore, only one of the above two classes of drugs should be used at a time.

LACK OF KNACK FOR NOVELTY — how can you expect a medical system that has barely realised the full potential of decades-old drugs, such as ACEIs and ARBs, to add novel agents to its prescriptions? Not surprisingly, we fail to adopt the newer medicines, drugs that have shown impressive improvements in the outcomes of diabetic kidney disease patients. Recently, a new class of drugs, SGLT2 inhibitors or Flozins, has emerged that sounds deceptively good for people with diabetes. When a trial was studying one of these agents, empagliflozin, for its benefits on heart disease in diabetic patients, the drug showed unexpected outcomes, reducing the number of not only heart-related events but also kidney-specific abnormalities. Even better, all these benefits came while many patients were already on other kidney-protective drugs. This means the advantages gained from Flozins were in addition to the benefits of ACEIs or ARBs. A later study that specifically focused on kidney outcomes of a similar drug, canagliflozin, replicated these results, rapidly bringing this group of medicines into the limelight. Since then, study after study has confirmed their efficacy and safety. Unfortunately, we are far from recognising the usefulness of these drugs, and despite being cheap drugs that are readily available, our doctors rarely include them in the regimen.

LACK OF KNACK FOR NOVELTY – how can you expect a medical system that has barely realized the full potential of decades-old drugs, such as ACEIs and ARBs, to add novel agents to its prescriptions? Not surprisingly, we fail to adopt the newer medicines, drugs that have shown impressive improvements in the outcomes of diabetic kidney disease patients. Recently, a new class of drugs, SGLT2 inhibitors or Flozins, has emerged that sounds deceptively good for people with diabetes. When a trial was studying one of these agents, empagliflozin, for its benefits on heart disease in diabetic patients, the drug showed unexpected outcomes, reducing the number of not only heart-related events but also kidney-specific abnormalities. Even better, all these benefits came while many patients were already on other kidney-protective drugs. This means the advantages gained from Flozins were in addition to the benefits of ACEIs or ARBs. A later study that specifically focused on kidney outcomes of a similar drug, canagliflozin, replicated these results, rapidly bringing this group of medicines into the limelight. Since then, study after study has confirmed their efficacy and safety. Unfortunately, we are far from recognizing the usefulness of these drugs, and despite being cheap drugs that are readily available, our doctors rarely include them in the regimen.

POORLY PREPARED FOR DIABETES IN ADVANCED CKD — as diabetic patients enter the advanced stages of kidney disease, most of them are found pumping insulin to quell their raging sugar levels. Unfortunately, in our standard practice, we simply pass over two groups of sugar-lowering drugs and go on to insulin instead, even though these drugs are safe to use and have a broader benefit profile than insulin. These drugs help regulate sugar levels as well as improve kidney and heart health. These groups are DPP-4 inhibitors, such as Sitagliptin and GLP-1 agonists, such as Liraglutide, both safe to use in advanced kidney disease. This doesn’t at all mean that a patient should drop insulin entirely. Instead, insulin is a very helpful tool for diabetic patients with advanced CKD. But adding DDP-4 inhibitors and GLP-1 agonists provides benefits beyond just lowering blood sugar levels.

INNOVATION VACUUM — while our doctors are still grappling with the issue of incorporating in their practice the established guidelines, modern medicine has already forayed into genomics and “omics,” techniques for developing new biomarkers of diabetic kidney disease. Genomics means the study of genes to identify genetic variants that influence the development of diabetic kidney disease. “Omics’ refers to techniques of protein and metabolite analysis in the blood and urine to identify and quantify these elements so that we can use them to predict and monitor the progression of diabetic kidney disease.

TAKE HOME — kidney disease is the most common small blood vessel complication of diabetes. Diabetic kidney disease accounts for a significant part of the kidney disease burden in the world. As a diabetes patient, you must understand the predisposition to kidney disease, its diagnostic tests and the best available treatments.

The writer is an award-winning internist and nephrologist. He tweets at @awaiszaka