Transcript PRESENTATION TITLE

Long-term impact of diabetes and
the importance of optimal
management of the condition
SECTION B
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/0914/0018a
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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Section B – 3 key learning objectives
• Type 2 diabetes is a progressive chronic disease requiring long-term
monitoring and intervention
• Sub-optimal treatment is associated with poor outcomes, including:
– Microvascular complications
– Cardiovascular complications
– Premature death
• By controlling blood glucose and blood pressure, these complications
may be preventable
4
The natural history of type 2 diabetes increases the risk
of microvascular and cardiovascular complications
Type 2
diabetes
Microvascular complications
include:
• Kidney damage1
• Eye damage1
End stage
kidney disease
Cardiovascular
death
• Nerve damage1
Cardiovascular complications
include:
• Coronary artery disease (leading to
heart attacks, angina)1
• Peripheral artery disease
(leg claudication, gangrene)1
Rising
blood
pressure
• Carotid artery disease (strokes,
dementia)1
* Renal haemodynamics altered, glomerular hyperfiltration
† Glomerular basement membrane thickening , mesangial expansion , microvascular changes +/-
References:
1. NICE clinical guideline 87. The management of type 2 diabetes. Issued: May 2009 last modified: July 2014.
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Untreated diabetic kidney disease can lead to
kidney failure
Without specific interventions, 20-40% of people with type 2 diabetes and
albuminuria progress to overt kidney disease1
Insulin resistance & arterial hypertension
Early glomerular
damage
Increasing
albuminuria
Structural
changes
(throughout
progression)
Adapted from: NKF K/DOQI Guidelines. Am J Kidney Dis. 2004 May;43(5 Suppl 1):S1-290.
Relationship of stage of kidney disease and
level of albuminuria to prognosis in CKD2
Vertical axis (Risk) shows hypothetical risks for
adverse outcomes of CKD, such as progression to
kidney failure or onset of cardiovascular disease
References:
1. American Diabetes Association. Diabetes Care 2004;27(suppl 1):s79-s83.
2. NKF K/DOQI Guidelines. Am J Kidney Dis. 2004 May;43(5 Suppl 1):S1-290.
Chronic kidney failure
Adapted from: American Diabetes Association. Diabetes Care 2004;27(suppl 1):s79-s83.
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Prevalence of kidney disease increases over time
after diagnosis of type 2 diabetes
Prevalence of kidney disease with increasing duration of diabetes
40
Prevalence in observed
population (%)
35.1%
30.2%
30
20.4%
Albuminuria or worse
kidney disease
20
10
Elevated plasma creatinine
or renal replacement
therapy
8%
0%
0.4%
0
(n=5097)
5
(n=4791)
0
0.8%
10
(n=2799)
2.3%
15
(n=435)
Time since diagnosis of type 2 diabetes (years)
(n=number alive and examined)
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Adapted from: Adler AI, Stevens RJ, Manley SE, et al. UKPDS64. Kidney International 2003;63:225-232.
Longer survival of people with diabetes may increase
the risk of developing kidney failure
• Without specific interventions, 20-40% of people with type 2 diabetes and
albuminuria progress to overt kidney disease1
• By 20 years after onset of overt kidney disease ˜20% of people progress to end
stage kidney disease1
• The rate of fall in GFR is highly variable between individuals, but not
substantially different between type 1 and type 2 diabetes1
• The risk of dying from coronary artery disease is higher in older people with
type 2 diabetes than those without; historically this may have affected the
number who progress to end stage kidney disease1
• As therapies and interventions for coronary artery disease continue to improve,
more people with type 2 diabetes may survive long enough to develop endstage kidney disease1
Reference:
1. American Diabetes Association. Diabetes Care 2004;27(suppl 1):s79-s83.
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Intensive blood glucose control in newly diagnosed patients
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
*Microvascular complications include retinopathy, nephropathy and neuropathy
†Intensive control with sulphonylureas or insulin, versus ‡conventional treatment of diet only
Reference:
1. UKPDS Group. UKPDS33. Lancet 1998;352:837-53
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Intensive blood glucose and blood pressure control
decreases the risk of complications
Intensive glucose control (HbA1c 7.0%) vs. conventional glucose control
(HbA1c 7.9%) reduces the risk of the following:
• Microvascular endpoints
• Any diabetes-related endpoints
• Diabetes related death
25%1
12%1
10%1
A tight BP control policy 144 / 82 vs. 154 / 87 mmHg reduces risk of:
•
•
•
•
Stroke
Microvascular endpoints
Deaths related to diabetes
Any diabetes-related endpoints
44%2
37%2
32%2
24%2
Microvascular endpoints include retinopathy, nephropathy and neuropathy.
Surrogate measures of microvascular disease include urinary albumin excretion and retinal photography.
References:
1. UKPDS Group UKPDS 33. The Lancet 1998;352;837-853.
2. UKPDS Group UKPDS 38. BMJ 1998;317(7160);703
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Diabetes is a burden to healthcare systems
• Diabetes is the most common cause of end stage kidney disease1
• Diabetes doubles the risk of
cardiovascular disease (heart attacks,
heart failure, angina, strokes)2
• Nearly 1 in 6 people with diabetes are
likely to have clinical depression3
• Intensive management and control of
diabetes can decrease the burden to
healthcare systems
References:
1. State of the Nation, England. Diabetes UK, 2012. http://www.diabetes.org.uk/Documents/Reports/State-of-the-Nation-2012.pdf. Last accessed 17.12.14.
2. Emerging Risk Factors Collaboration (2010). Lancet 375 (9733); 2215–2222 .
3. Ali S et al; Diabet. Med. 23 (11) (2006) 1165–1173.
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CKD has a considerable financial impact
• The annual cost of chronic kidney disease (CKD) to the NHS in England was
estimated at £1.45 billion in 2009-101
– Represents 1.3% of all NHS spending that year1
– Equivalent to £1 in every £77 spent2
• There are believed to be between 0.9 million and 1.8 million people in England
who have undiagnosed CKD3
The cost of implementing UK guidelines for a practice of 10,000 patients
would be recouped by delaying dialysis for one year in one person4
References:
1. NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014.
2. NHS Choices. 'One million people' with 'undiagnosed' chronic kidney disease. Behind the Headlines. Tuesday August 7 2012. Available at:
http://www.nhs.uk/news/2012/08august/ Pages/One-million-people-with-undiagnosed-chronic%20kidney-disease.aspx. Website last accessed on 16.12.14 .
3. Kerr M, Bray B, Medcalf J, et al. Nephrol Dial Transplant 2012;27(Supple 3):iii73-iii80.
4. Klebe B, Irving J, Stevens PE, et al. Nephrol Dial Transplant 2007;22: 2504–2512.
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Distribution of costs attributable to CKD, 2009–101
Renal Replacement Therapy
Renal Primary Care
Antihypertensive
prescribing
£152m
Transplantation
£225m
Primary care tests and
consultations
£143m
Excess non-renal care attributable to CKD
BMD* &
anaemia
£27m
Renal secondary care
Dialysis
£505m
Dialysis
transport
£50m
Excess
MI
£95m
Renal
admissions
£75m
Excess
stroke
£82m
Excess length of stay
£46m
Nephrology
consultations
(Non-RRT)
£53m
Excess MRSA
£1m
*BMD=bone mineral density
Reference:
1. Kerr M, Bray B, Medcalf J, et al. Nephrol Dial Transplant 2012;27(Supple 3):iii73-iii80.
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Section B – summary
• Type 2 diabetes increases the risk of microvascular and cardiovascular
complications
• Untreated diabetic kidney disease can lead to kidney failure
• The risk of kidney disease increases over time since diagnosis
• As people live longer, more people with type 2 diabetes will be at risk of
kidney disease
• Intensive blood glucose control decreases the risk of microvascular
complications
• Diabetes and CKD represent a significant financial burden to healthcare
systems
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