Transcript PRESENTATION TITLE

Chronic kidney disease in people
with type 2 diabetes – A learning
resource for Primary Care
SECTION A
Introduction and overview of
chronic kidney disease (CKD)
in people with diabetes
These slides were sponsored by Janssen and developed in conjunction with the BRS CKD Strategy Group, following an advisory board that
was organised by Janssen. Bedrock Healthcare Communications provided editorial support to members of the advisory board in developing
the slides. Janssen reviewed the content for technical accuracy. The content is intended for a UK healthcare professional audience only.
JOB CODE PHGB/VOK/0914/0018
Date of preparation: January 2015
Objectives and background for this learning resource
Introduction:
This learning resource has been developed as part of a medical education initiative supported by
Janssen. The content of this slide kit has been developed by an advisory board of renal physicians, GPs
and specialist nurses. The panel of experts includes members of the British Renal Society Chronic Kidney
Disease (CKD) Strategy Group. Bedrock Healthcare, a medical communications agency, has provided
editorial support in developing the content; Janssen has reviewed the content for technical accuracy.
Educational objectives:
•
To provide clear and applicable clinical guidance on chronic kidney disease (CKD) in people with type
2 diabetes to primary care healthcare professionals
•
To advise primary healthcare professionals on what people with diabetes need to know about their
own condition with relation to CKD
Usability objectives:
•
To provide essential, relevant and up to date information in concise presentations
•
To enable primary healthcare professionals to locate, select and use the content of the learning
resource, as appropriate to their needs
•
To enable secondary care experts in CKD to refer their primary care colleagues to the resource
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Contents overview
This learning resource comprises the following 10 sections (A-E):
Section A
Introduction and overview of chronic kidney disease (CKD) in people
with diabetes
Section B
Long-term impact of diabetes and the importance of optimal
management of the condition
Section C
Pathophysiology of diabetic nephropathy & risk factors for the
development of CKD
Section D
Appropriate monitoring for complications of diabetes in primary care –
CKD as one of these complications
Section E
Prevention of diabetic kidney disease
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Contents overview (cont.)
This learning resource comprises the following 10 sections (F-J):
Section F
Optimal management of diabetic kidney disease:
hypertension and glycaemia
Section G
How to involve people with diabetes and CKD in their own care – what
information must they have to manage their own condition effectively?
Section H
What does the future hold for a person with well-managed diabetes
and CKD?
Section I
What do the guidelines say and what do they mean in terms of the
day-to-day management of CKD in people with diabetes?
Section J
Sources of further information and reading list
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Introduction and overview of
chronic kidney disease (CKD)
in people with diabetes
SECTION A
Section A – 3 key learning objectives
• Objectives and background to this learning resource
• Key definitions used throughout the learning resource
• Overview of chronic kidney disease (CKD) in type 2 diabetes, including:
– The scale of the problem
– CKD in people with diabetes may be PREVENTABLE not inevitable
– Outcomes for people with type 2 diabetes and CKD
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Key definitions (slide 1 of 3)
Term or phrase
Definition
Albumin:Creatinine Ratio
(ACR)
A test used to detect and quantify albumin in a urine sample
Albuminuria
An abnormally increased amount of albumin in the urine
Protein leaking from the blood into the urine through the kidney is a sign of
kidney disease
There are three categories, based on the quantity of albumin in the urine:
• Normal to mildly increased (ACR <3mg/mmol)
• Moderately increased (ACR 3-30mg/mol)
• Severely increased (ACR >30mg/mol)
Chronic Kidney Disease
(CKD)
CKD is a progressive loss in kidney function over a period of months or
years. The stage of CKD is based on the level of GFR irrespective of the
cause of kidney disease:
Stage 1 = kidney damage with normal or raised GFR ≥90mL/min/1.73m2
Stage 2 = kidney damage with mildly reduced GFR 60-89mL/min/1.73m2
Stage 3 = moderately reduced GFR 30-59mL/min/1.73m2
Stage 4 = severely reduced GFR 15-29mL/min/1.73m2
Stage 5 = Kidney failure GFR of <15mL/min/1.73m2 or dialysis
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Key definitions (slide 2 of 3)
Term or phrase
Definition
Diabetic kidney disease or
diabetic nephropathy
A kidney disease which is specific to diabetes. The first manifestation is
usually albuminuria. It is often, but not exclusively, associated with
retinopathy
Estimated Glomerular
Filtration Rate
(eGFR)
A test of kidney function which can be used to monitor progression of kidney
disease. It can be estimated using serum creatinine (eGFRcreatinine) or
using cystatin C (eGFRcystatinC)
End Stage Kidney
Disease
(ESKD)
This is defined as irreversible decline in a person's own kidney function,
which is severe enough to be fatal in the absence of dialysis or
transplantation. The GFR in ESKD is <15ml/min/1.73 m2 .
Macroalbuminuria
The current equivalent term is ‘severely increased albuminuria’
TERMINOLOGY NO LONGER
RECOMMENDED (NICE, 2014)
Microalbuminuria
TERMINOLOGY NO LONGER
RECOMMENDED (NICE, 2014)
The current equivalent term is ‘moderately increased albuminuria’. It is a
small increase in the urinary excretion of the protein albumin – an early sign
of diabetic kidney disease
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Key definitions (slide 3 of 3)
Term or phrase
Definition
Proteinuria
Excess protein in the urine. Because most of the protein that leaks into the
urine as a result of glomerular and vascular damage is albumin, the terms
proteinuria and albuminuria are often used interchangeably; the 2014 NICE
CKD guideline uses proteinuria
Renal Replacement
Therapy (RRT)
A term to describe dialysis or kidney transplant
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What is diabetic kidney disease?
Diabetic kidney disease (or diabetic nephropathy) is a ‘clinical syndrome’
usually characterised by:
• Persistent albuminuria
• High blood pressure
• Progressive decline in eGFR
• Increased risk of cardiovascular mortality and morbidity
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There are some myths about diabetic kidney disease
(slide 1 of 2)
Myth
Fact
Progression of diabetic
kidney disease is
inevitable
Diabetic kidney disease can sometimes be prevented and progression can
be slowed through tight control of blood pressure and blood glucose
It occurs late in the natural
history of diabetes
Time to development depends on how well risks are managed
Diabetic kidney disease is
more common in type 1
diabetes compared with
type 2
NICE CKD guidelines do not differentiate between type 2 and type 1
diabetes – the risks of diabetic kidney disease are likely to be similar
between types
It occurs exclusively in
people with diabetic
retinopathy
It is often, but not exclusively, associated with diabetic retinopathy
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There are some myths about diabetic kidney disease
(slide 2 of 2)
Myth
Fact
Albuminuria is always a
feature of diabetic kidney
disease
Albuminuria is a marker of kidney disease, but even when albuminuria is not
observed in a diabetic patient, it is not a guarantee that the patient is free of
chronic kidney disease
Diabetic kidney disease,
when established, is easy
to treat
It is easier, and less costly, to prevent than to treat
People with diabetes are
rarely interested in
managing the future risk
from their disease
With appropriate information and skills, patients can be active in their
treatment
People with diabetic
kidney disease need to
see a nephrologist
Stable diabetic kidney disease can be managed in primary care; referral
depends on rate of progression (see Section F for more information on
referrals)
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Diabetes and CKD are both common conditions
Chronic Kidney Disease (CKD)
Diabetes
• 4.3 per 100 people aged 18+ registered at
GP practices in England have been
diagnosed with CKD1
• 6.0 per 100 people aged 17+ registered
at GP practices in England have been
diagnosed with diabetes1
• That is 246 in an average practice*2
• That is 348 in an average practice†2
• Data suggest an indicative benchmark rate
of 7.6% for the number of adults with CKD3
“Under-diagnosis is still an issue in primary care. The number of people identified on
CKD registers in England is significantly below other measures of prevalence”3
Those with CKD stages 1-3 may be most at risk of under-diagnosis
* Average practice of 5,721 patients aged ≥182
† Average practice of 5,805 patients aged ≥172
References:
1. Health and Social Care Information Centre. Quality and Outcomes Framework – 2012-13: Annex 1, Report tables and charts. Available at:
http://www.hscic.gov.uk/article/2021/Website-Search?productid=12972&q=figure+4.1+AND+raw+prevalence+rates+for+all+qof+registers+2012%2f13&sort
=Relevance&size=10&page=1&area=both#top Website last accessed on 12.11.14.
2. Health and Social Care Information Centre. Numbers of Patients at a GP Practice single year of age - October 2014 – GP. Available at:
http://www.hscic.gov.uk/article/2021/WebsiteSearch?productid=16172&q=number+of+patients+at+a+gp+practice+single+year+of+age+october+2014&sort=Relevance&size=10&pag
e=1&area=both#top Website last accessed on 12.11.14.
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3. NICE Commissioning Guide CMG37. Early identification and management of chronic kidney disease in adults. July 2012. available at:
https://www.nice.org.uk/guidance/cmg37/resources/non-guidance-early-identification-and-management-of-chronic-kidney-disease-in-adults-pdf Website last accessed on 06.01.15.
Diabetic kidney disease is common
• UK prevalence in 2011 of CKD as a
result of diabetes was reported to
range from 18% to >30% in all
people with diabetes1
• In 2012, 25.6% of primary renal
diagnoses in patients commencing
renal replacement therapy (RRT) in
the UK were attributed to diabetes2
– This figure rises to 28.6% in patients
aged <65 years
• People with diabetes have the
highest rates of RRT compared with
other conditions including
hypertension, polycystic kidney and
renal vascular disease (see graph)2
Primary renal diagnosis RRT
incidence rates (2012) per million
population (unadjusted)2
35
30
England
N Ireland
25
Scotland
Wales
20
UK
15
10
5
0
Diabetes
Hypertension
Polycystic
kidney
Renal
vascular
disease
* Average practice of 5,721 patients aged ≥182
† Average practice of 5,805 patients aged ≥172
Note: RRT indicates end stage kidney disease
Reference:
1. NHS Diabetes Kidney Care. Diabetes with Kidney Disease: Key Facts. 2011. Available at: www.yhpho.org.uk/resource/view.aspx?RID=105786 Website accessed on 15.01.15
2. The Renal Association. UK Renal Registry 2013. Available at: https://www.renalreg.org/wp-content/uploads/2014/09/Report2013.pdf Website last accessed on 12.11.14
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Who is at risk?
Type 2 diabetes is up to six times more common in people of South Asian descent
and up to three times more likely among people of African-Caribbean descent1
– The graphs show prevalence of self-reported doctor diagnosed diabetes in England
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% Prevalence of Diabetes in Male
minority Ethnic Groups
10.1
10
10
8.2
8
6
4
2
0
7.3
5
4.3
3.8
3.6
10
9
8
7
6
5
4
3
2
1
0
% Prevalence of Diabetes in Female
minority Ethnic Groups
8.6
8.4
5.9
5.2
3.4
3.3
2.3
Reference:
1. Diabetes UK. Diabetes in the UK 2012 Key statistics on diabetes’. http://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2012.pdf Website last accessed on
12.11.14
2.1
14
Who is at risk of end stage kidney disease?
Rates of RRT are higher in areas with a higher black and minority ethnic (BME)
population compared with areas with a lower BME population1
Crude rate of RRT per million population
1400
1200
1000
800
600
400
200
0
Manchester Cumbria (1.5% Bradford &
(33.4% nonnon-white)
Airedale
white)
(32.6% nonwhite)
North West
East Riding of Leicester City
Yorkshire
(49.5% non(1.9% nonwhite)
white)
Yorkshire & Humber
Lincolnshire
(2.4% nonwhite)
East Midlands
Newham
(71.0% nonwhite)
Richmond &
Twickenham
(14.0% nonwhite)
London
Note: Renal Replacement Therapy (RRT) indicates end stage kidney disease
Reference:
1. UK Renal Registry. The Renal Association. 2013. Available at: https://www.renalreg.org/wp-content/uploads/2014/09/Report2013.pdf Website last accessed on 12.11.14
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The prevalence of diabetic kidney disease
is increasing
• The rapidly increasing prevalence of
diabetes worldwide virtually assures
that the proportion of diabetic kidney
disease will continue to rise1
• In 2013, diabetes was the primary
diagnosis for 15.9% of patients
undergoing RRT in the UK2
50,000
40,000
Peritoneal dialysis
Home haemodialysis
Haemodialysis
Transplant
30,000
20,000
Year
Adapted from The Renal Association. UK Renal Registry 2014.
*Renal replacement therapy includes peritoneal dialysis, haemodialysis and transplant.
References:
1. National Kidney Foundation KDOQI Clinical Practice Guidelines for Diabetes and CKD: 2012 Update. Available at http://www.kidney.org/sites/default/files/docs/diabetes-ckdupdate-2012.pdf Website last accessed on 12.11.14.
2. . The Renal Association. UK Renal Registry 2014. Available at https://www.renalreg.org/publications-reports/#reports. Website last accessed on 20.02.15.
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2013
2012
2011
2010
2008
2009
2007
2006
2005
2004
2002
2003
2001
2000
1999
10,000
1997
1998
• In the UK, according to The Renal
Association UK Renal Registry 2014,
the number of people on renal
replacement therapy (RRT)* has
increased steadily from 1997 to 20132
60,000
Number of patients
• Data from 2012 showed that diabetes
was the leading cause of CKD in the
US1
Number of patients on each treatment
modality of RRT at the end of each year
1997–2013
The prevalence of CKD and diabetes varies, but the
general approach is the same
• There is a high degree of variation in
the prevalence of CKD and diabetes
between GP practices in England1
Variation in raw prevalence rates (%)
at GP practices for CKD and diabetes
QOF registers, 2012/13
• The reasons for this variation are
complex, but may include underdiagnosis and population differences2
– Controlling blood glucose and blood
pressure
– Lifestyle interventions e.g. diet,
exercise and smoking cessation
Diabetes
Lower Quartile
2.7
5.2
Upper Quartile
5.4
7.1
50
40
Prevalence (%)
• The general approach remains the
same to reduce the risk of
development and progression of
diabetic kidney disease:
CKD
30
20
10
0
Chronic Kidney
Disease
Diabetes Mellitus
(Diabetes)
References:
Adapted from Health and Social Care Information Centre. Quality and Outcomes Framework – 2012-13: Annex 1
1. Health and Social Care Information Centre. Quality and Outcomes Framework – 2012-13: Annex 1, Report tables and charts. Available at:
http://www.hscic.gov.uk/catalogue/PUB12262 Figure 4.3. Website last accessed on 12.11.14.
2. NICE Commissioning Guide CMG37. Early identification and management of chronic kidney disease in adults. July 2012. available at:
17
https://www.nice.org.uk/guidance/cmg37/resources/non-guidance-early-identification-and-management-of-chronic-kidney-disease-in-adults-pdf Website last accessed on
06.01.15.
Kidney disease powerfully predicts increased
mortality in people with diabetes1
• Without kidney disease, diabetes is
not associated with a large increase
in mortality risk1
• The co-existence of kidney
disease and diabetes is
associated with greater mortality
than the sum of excess risks
associated with either diabetes or
kidney disease alone1
Ten-year mortality in type 2 diabetes by kidney
disease manifestation
Standardised ten-year cumulative
incidence of mortality
• The increased mortality risk in
people with type 2 diabetes is
concentrated in those with diabetes
AND kidney disease1
70
47.0%
60
50
23.9%
40
17.8%
30
20
4.1%
10
0
No Kidney Albuminuria
Disease
Impaired Albuminuria &
GFR Impaired GFR
Absolute differences in mortality risk were estimated using linear regression and
were adjusted for age, sex, and race. Standardised 10-year all-cause cumulative
incidences were estimated for the mean levels of the covariates in the study
population. The dashed line indicates mortality in people without diabetes or
kidney disease (the reference group). The numbers above bars indicate excess
mortality above the reference group. Error bars indicate 95% CIs.
Adapted from Afkarian M, Sachs MC, Kestenbaum B, et al. J Am Soc Nephrol 24: 302–308, 2013.
Reference:
1. Afkarian M, Sachs MC, Kestenbaum B, et al. J Am Soc Nephrol 24: 302–308, 2013.
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Intensive blood glucose control decreases the risk of
developing microvascular complications†
12
p=0.0099
Absolute risk: events per
1000 patient/years
10
~25% difference in risk
8
Intensive
treatment*
Conventional
treatment**
Absolute
risk = 11.4
6
Absolute
risk = 8.8
4
2
0
Microvascular complications
*Intensive control with sulphonylureas or insulin, versus **conventional treatment of diet only
† Microvascular complications include retinopathy, nephropathy and neuropathy
Reference:
1. UKPDS Group. UKPDS33. Lancet 1998;352:837-53
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Section A – summary
Diabetic kidney disease is:
• Kidney disease caused by diabetes specifically
• Common
• Increasing in prevalence
• Associated with greatly increased mortality compared with people with diabetes
who do not have diabetic kidney disease
– 4.1% vs. 47.0% ten-year mortality1
• Preventable
Reference:
1. Afkarian M, Sachs MC, Kestenbaum B, et al. J Am Soc Nephrol 24: 302–308, 2013.
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