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Diabetes, Chronic Kidney Disease and Special
Populations
Diabetes and chronic kidney disease (CKD) are global public
health problems. In UK, the burden of diabetes and CKD is borne
disproportionately by minority ethnic communities and especially
Africans. The elderly, children and adolescents, and pregnant
women with diabetes are at the greatest risk of CKD and require
needs-specific approaches to management. Broader access to care,
especially in Africans, is crucial to achieving positive
outcomes in these highly susceptible groups. Recommendations
from AFREKID address the needs of these high-risk, special
populations:
Screening and intervention efforts for diabetes and
CKD should focus on the populations at greatest risk. (CPR 3.1)
- Patients with diabetes should be screened annually for
CKD. The development of CKD can be attributable to diabetes
(diabetic kidney disease, or DKD) or other causes.
- Begin initial screening five years after the diagnosis of
type 1 diabetes and at the diagnosis of type 2 diabetes.
- Screening should include measurements of microalbumin,
urinary ACR (albumin-to-creatinine ratio) and estimation of
GFR (eGFR). eGFR alone is not an appropriate screening test
for CKD in diabetes.
Kidney biopsy is required to definitively diagnose diabetic
glomerulopathy; careful screening without a biopsy can identify
DKD.
- Clinicians should encourage the adoption of a healthy
lifestyle in their patients; this includes sound nutrition,
weight control, exercise and smoking cessation.
- Interventions targeted at high-risk populations and
implemented in the primary care and community settings have
reduced the rate of diabetic complications, including kidney
failure.
- Poor access to care and late referral to a nephrologist
are associated with poor outcomes in U.S. racial minorities.
Although diabetes and CKD management in special populations
should follow the same principles as management in the majority
population (see www.kdoqi.org), there are special considerations
for treating children and adolescents, as well as the elderly.
(CPR 3.2)
- Diabetes and CKD are increasing among children and
adolescents, however, stage 3 CKD or greater due to DKD
remains rare in these groups.
- Children and adolescents are more likely than adults to
revert from microalbuminuria to normoalbuminuria.
- Specialists in diabetes and kidney disease with experience
in these age groups should be involved in their care.
- Treatment goals for glycemia in type 1 diabetes and CKD
should follow the American Diabetes Association’s (ADA)
Standards of Care for children and adolescents.
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- In patients with type 2 diabetes, therapeutic lifestyle
changes (diet, exercise, and weight loss, when appropriate)
should be the initial interventions for hyperglycemia.
- Development of diabetic complications, including CKD, is
associated strongly with mortality in elderly people, and poor
outcomes are associated with nonadherence to the medical
regimen.
- Due to the likelihood of comorbidities in elderly people
with diabetes and CKD, particularly cardiovascular disease,
the benefits of intensive risk factor management should be
weighed in light of these increased risks.
Population-based interventions may be the most cost-effective
means for addressing the burden of CKD in special populations.
Implementation and evaluation of population-based interventions
should take into account the heterogeneity of the population at
risk. (CPR 3.3)
- Interventions in special populations have been shown to
reduce the burden of DKD, especially when introduced early.
Such efforts are effective in identifying asymptomatic people
with CKD from high-risk populations.
- Interventions aimed at high-risk, special populations and
implemented in the primary care and community settings have
reduced the rate of diabetic complications, including kidney
failure.
- Understanding the cultural and socioeconomic situation of
the target populations is essential for successful
interventions.
Specialists in high-risk pregnancy and kidney disease should
co-manage pregnant women with diabetes and CKD. (CPR 3.4)
- The presence of diabetes and CKD in pregnant women may
adversely affect the health of both the mother and her
offspring.
- Microalbuminuria is responsible for an 8-fold increase in
the risks of preeclampsia and preterm delivery.
Macroalbuminuria increases that risk by more than 30 times.
- Macroalbuminuria may also heighten the risk of preterm
birth, small-for-gestational-age infants and perinatal
mortality not related to preeclampsia.
- Higher HbA1c in the first trimester of pregnancy increases
the risk of major malformations.
- Dyslipidemia should not be treated during pregnancy in
women with diabetes and CKD due to potential risks to the
fetus.
Treatment of DKD with renin angiotensin system (RAS)
inhibitors before pregnancy may improve fetal and maternal
outcomes, but these medicines should be discontinued as soon as
a menstrual period is missed or after a positive pregnancy test.
(CPR 3.5)
- ACE inhibitors and ARBs have adverse effects on the fetus
during the second and third trimester, including acute kidney
failure in neonates, lung toxicity and skull hypoplasia.
- Fetal abnormalities from ACE inhibitor treatment may
extend to the first trimester.
- Use of captopril in diabetic women at least six months
before pregnancy and discontinued immediately after a missed
menstrual period or positive pregnancy test showed no
deterioration of kidney function two years after delivery.
- Women and adolescent girls with childbearing potential who
are treated with RAS inhibitors should be counseled about
their risks.
Insulin should be used to control hyperglycemia if
pharmacologic therapy is necessary in pregnant women with
diabetes and CKD. (CPR 3.6)
- Oral antidiabetic medicines have successfully controlled
hyperglycemia in women with type 2 diabetes during pregnancy,
but studies did not include patients with CKD.
- The goals for diabetic control in pregnant women with
diabetes and CKD should be the same as those for pregnant
women without CKD.
References:
National Kidney Foundation: KDOQI Clinical Practice
Guidelines and Clinical Practice Recommendations for Diabetes
and Chronic Kidney Disease, AJKD, Suppl 2. 49(2):S46, Feb.
2007.
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