Transforming the Care of Patients with Diabetic Kidney Disease

Abstract

Diabetes and its associated complications pose an immediate threat to humankind. Diabetic kidney disease is one of the most devastating complications, increasing the risk of death more than ten-fold over the general population. Until very recently, the only drugs proven and recommended to slow the progression of diabetic kidney disease were angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers, which act by inhibiting the renin-angiotensin system. Despite their efficacy as kidney and cardiovascular protective therapies and as antihypertensive agents, renin-angiotensin system inhibitors have been grossly underutilized. Moreover, even when renin-angiotensin system inhibitors are used, patients still have a high residual risk of diabetic kidney disease progression. Finally, the kidney-protective effect of renin-angiotensin system inhibitors has been categorically demonstrated only in patients with macroalbuminuria included in the Irbesartan Diabetic Nephropathy Trial (IDNT) and Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) trials, not in other individuals. The lack of new therapies to treat diabetic kidney disease over the past 2 decades has therefore represented a tremendous challenge for patients and health care providers alike. In recent years, a number of powerful new therapies have emerged that promise to transform care of patients with diabetes and kidney disease. The challenge to the community is to ensure rapid implementation of these treatments. This white paper highlights advances in treatment, opportunities for patients, challenges, and possible solutions to advance kidney health, and introduces the launch of the Diabetic Kidney Disease Collaborative at the American Society of Nephrology, to aid in accomplishing these goals.

Keywords: SGLT2 inhibitor; diabetes; disparity; equity; kidney disease.

Figure 1.

An average patient in CREDENCE, represented by a male patient with type 2 diabetes, age 63, with an eGFR of 56 ml/min per 1.73 m², receiving standard care in CREDENCE would need to start dialysis at age 73; the same patient receiving treatment with the SGLT2 inhibitor canagliflozin, in addition to standard care, would not require dialysis until age 88. To delay onset of dialysis treatment by 15.1 years is a profound benefit, especially given the projected 5-year survival of only 35% for such a patient receiving hemodialysis. Graphic courtesy of A. Levin and V. Perkovic. CREDENCE, Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy.

Figure 2.

Current stakeholders, challenges, and possible solutions for implementation of new therapies.