The impact of disadvantage on the development and progression of diabetic kidney disease

Abstract

Background: Disadvantaged people include those experiencing economic, social or educational deprivation and, in some cases, those undergoing rapid transition from subsistence to industrial economies. Disadvantaged people worldwide are affected disproportionately by the global epidemic of diabetes. They are also at increased risk of kidney disease attributable to diabetes, and for many, the cost of managing their kidney disease far exceeds their available resources.

Methods: We review factors associated with disadvantage that may increase the risk of diabetic kidney disease, and the barriers to care that hinder attempts to provide an adequate therapeutic response.

Results and conclusions: A rapidly rising prevalence and magnitude of obesity among children and adults, increasing frequency of intrauterine exposure to diabetes, and inadequate access to healthcare are responsible, in part, for a surge in the frequency of diabetes and, in turn, diabetic kidney disease among disadvantaged people. These factors may also predispose to an earlier onset of diabetes and kidney disease, thereby perpetuating the disadvantage by reducing the earning potential of those affected through illness and disability.

Figure 1

Estimated number of adults with diabetes in developed and developing countries. Adapted with permission of the World Health Organization [1].

Figure 2

Prevalence of elevated urinary albumin excretion (albumin-to-creatinine ratio > 30 mg/g) in diabetic Pima Indians, by birth weight, adjusted for age, sex, duration of diabetes, HbA1C and mean arterial pressure. Dashed lines represent twice the point-wise asymptotic standard errors of the estimated curve, and the vertical tics on the x-axis are a frequency plot of birth weights. Values of the covariates were set to their sample means. Reprinted with permission from Oxford University Press [10].

Figure 3

Predicted prevalence (95% CIs) of elevated UAE (albumin-to-creatinine ratio > 30 mg/g) in diabetic Pima Indians, by maternal diabetes status, adjusted for age, sex, duration of diabetes, HbA1C and MAP. Values of the covariates were set to their sample means. In this figure, “Prediabetic” means that the mother did not have diabetes during pregnancy but developed Type 2 diabetes later in life. Copyright^© 1998 American Diabetes Association. From Diabetes, Vol. 47, 1998; 1489–1494. Reprinted with permission from the American Diabetes Association [13].

Figure 4

Cumulative incidence of diabetic end-stage renal disease in Pima Indians by age at onset and duration of diabetes. Adapted with permission [21].