CME

Updated management of chronic kidney disease in patients with diabetes Virginia McCoy Hass, DNP, RN, FNP-C, PA-C, MSN

ABSTRACT Chronic diseases, including chronic kidney disease (CKD), are the primary threat to global public health in the 21st century. Recently updated guidelines from the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative provide patient care benchmarks that physician assistants can use when caring for patients with diabetes and CKD and developing clinical performance improvement plans. Keywords: chronic kidney disease, diabetes, guidelines, KDOQI, KDIGO, primary care

Diabetic nephropathy

Protein (albumin) leaks from capillaries

Proteins excreted in urine

Apply the updated KDOQI guidelines to the management of hyperglycemia and general diabetes care in patients with chronic kidney disease. Apply the updated KDOQI guidelines to the management of dyslipidemia in patients with diabetes and chronic kidney disease. Apply the updated KDOQI guidelines to the management of albuminuria in normotensive patients with diabetes.

Nephron enlarged

Protein (albumin) and waste enter kidney with blood Renal artery Renal vein

High levels of protein in urine

C

hronic diseases are the primary threat to global public health in the 21st century. In 2011, chronic kidney disease (CKD) joined diabetes, cardiovascular disease, chronic lung disease, and cancer as one of the five major chronic diseases threatening global public health.1 Diabetes is the leading risk factor for CKD in the United States (Figure 1).1,2 The estimated prevalence of diabetes in the United States is 8.3% of the population (25.8 million) and is increasing in all geographic areas.2 From 1995 to 2010, the age-adjusted prevalence of diabetes increased by 50% or more in 42 states; in 18 of those states, the increase was 100% or

more (Figure 2).2 Primary care clinicians, including physician assistants (PAs), care for many patients with chronic diseases, including those with CKD and diabetes.3-5 Despite the rise in CKD prevalence, the incidence of end-stage renal disease (ESRD) due to diabetes has recently declined due to earlier therapeutic intervention in this population.1

Virginia McCoy Hass is an assistant clinical professor and nurse practitioner program director in the Betty Irene Moore School of Nursing at the University of California at Davis. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000447000.04339.f9 Copyright © 2014 American Academy of Physician Assistants

PATHOPHYSIOLOGY Diabetic nephropathy is a microvascular complication of diabetes.6 Characterized by albuminuria (a level of more than 300 mg/dL) and decreased glomerular filtration rate (GFR), diabetic nephropathy often is present in patients when type 2 diabetes is diagnosed.6 In patients with type

JAAPA Journal of the American Academy of Physician Assistants

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

www.JAAPA.com

17

ILLUSTRATION © JENNIFER SMITH, MEDICAL ILLUSTRATOR

Learning objectives

CME

Key points A target A1C of about 7% is recommended for patients with stages 1 to 3 CKD and diabetes to prevent or delay progression of the microvascular complications of diabetes, including CKD. Patients at risk for hypoglycemia, in particular those with stage 4 or 5 CKD, should not be treated to an A1C of less than 7%. LDL cholesterol-lowering therapy with a statin or statin plus ezetimibe is recommended to reduce the risk of major CV events in patients with stages 1 to 4 CKD and diabetes. ACE inhibitors and ARBs are not recommended for primary prevention of kidney disease in normotensive normoalbuminuric patients with diabetes.

1 diabetes, the prevalence of diabetic nephropathy is estimated at 25%, with the onset 7 to 10 years after diagnosis of diabetes.7 As kidney disease progresses, renal mass diminishes.6 The stages of CKD, as defined by National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI), are based on the estimated GFR (Table 1), which is contingent on sex, age, race, weight, and serum creatinine.8 Although the mechanisms for increased risk are not fully understood, stage 3 or higher CKD is an independent risk factor for cardiovascular (CV) events and death.9 Patients with diabetes and stages 3 to 5 CKD also are at increased risk of hypoglycemia due to decreased kidney gluconeogenesis, impaired clearance of insulin and oral agents such as the sulfonylureas, and decreased breakdown of insulin in peripheral tissues.6

PRIMARY CARE MANAGEMENT OF CKD In 2007, the National Kidney Foundation published guidelines to assist clinicians in managing patients with diabetes and CKD. 10 The primary health outcome addressed by the KDOQI guideline update is all-cause mortality. Secondary health outcomes include ESRD, CV death and nonfatal CV events, vision loss, amputation, and severe hypoglycemic events.11 Since the original publication, a signifi cant body of high-quality evidence has emerged, resulting in updates to three of the nine practice guidelines (Table 2).11 Guideline statements are graded by strength of recommendation (Table 3) and quality of the supporting evidence (Table 4).11 KDOQI GUIDELINE UPDATES Management of hyperglycemia and general diabetes care in CKD (Guideline 2). The KDOQI update provides clearer guidance by stratifying target A1C level by the patient’s risk of hypoglycemia and comorbidities. Three studies published since the original KDOQI guideline demonstrate that glycemic control to near-normal levels (an A1C of less than 7%) prevents or decreases progression of diabetic kidney disease endpoints in patients with type 2 diabetes.12-14 The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) demonstrated a 21% reduction of the endpoints of new macroalbuminuria, doubling of serum creatinine, need for kidney replacement therapy, or death.12 The Veterans Affairs Diabetes Trial (VADT) demonstrated a 37% reduction in macroalbuminuria and a 32% reduction in microalbuminuria.13 The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study showed a

6 5

Odds ratio

4 3 2 1 0 Diabetes

Self-reported diabetes

Hypertension

Self-reported hypertension

Self-reported cardiovascular disease

BMI ≥30

FIGURE 1. Adjusted odds ratios of CKD in NHANES participants, by risk factor1

18

www.JAAPA.com

Volume 27 • Number 6 • June 2014

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Updated management of chronic kidney disease in patients with diabetes

TABLE 1.

Stages of CKD7

Stage

Description

Estimated GFR (mL/min/1.73 m2)

1

Kidney damage with normal or increased GFR

>90

2

Kidney damage with mild decrease in GFR

60-89

3

Moderate decrease in GFR

30-59

4

Severe decrease in GFR

15-29

5

Kidney failure

Updated management of chronic kidney disease in patients with diabetes.

Chronic diseases, including chronic kidney disease (CKD), are the primary threat to global public health in the 21st century. Recently updated guideli...
481KB Sizes 1 Downloads 5 Views