Diabetic Kidney Disease: Patients Are Not Getting the Treatment They Need

A new study has found that recommendations and therapies for the diagnosis, prevention, and treatment of chronic kidney disease (CKD) were woefully underutilized in a leading American medical center.

Chronic kidney disease is a serious complication of diabetes that has significant effects on patients’ health and quality of life. While early stages of kidney disease do not cause any symptoms, as the condition progresses it can become an immense medical, financial, and emotional burden. When diet and blood sugar control are not enough to prevent kidney damage, patients may require dialysis and, eventually, a kidney transplant.

About half of the world’s people with type 2 diabetes will develop kidney disease, and about half of them will die from kidney failure or cardiovascular events attributed to kidney disease, according to a 2022 study.

Is CKD identified quickly enough, and treated properly? Do American patients get what they need to prevent the development and progression of diabetic kidney disease? A group of experts with the Cleveland Clinic, a leading non-profit academic medical center, conducted a retrospective study of real-world treatments to find out.

The study, published in the Journal of Diabetes and its Complications, found a major gap between clinical guidelines and actual practice, indicating that few patients were getting the attention that the medical system could offer:

Very few patients had their urine protein assessed as recommended
A minority of eligible patients were prescribed drugs that can protect the kidneys
Visits with specialists such as nephrologists and endocrinologists were rare

It would appear that Americans with diabetes are not getting the support that they need to evaluate, prevent, or treat chronic kidney disease.

Diabetes Daily talked with Kevin Pantalone, DO, an endocrinologist and one of the study’s authors. Dr. Pantalone explained the nature of this CKD treatment shortfall, and what to do about it.

DD: Only about 20 percent of people with type 2 diabetes received a urine protein assessment during the year that your team examined, which the study calls “dismal.” How often should these tests be performed?

Dr. Pantalone: Ideally, all patients with type 2 diabetes should undergo assessment of urine protein on an annual basis.

Studies have shown that many patients with T2D have had the condition for nearly five years prior to the formal diagnosis being made by their healthcare provider. Thus, some patients may already have evidence of CKD at or near the time of diagnosis.

Patients with proteinuria need to be treated more aggressively. If one does not check the urine protein in these patients, one does not know who is at a higher risk of progressing to more severe forms of CKD. Screening is important, as often patients with proteinuria are asymptomatic. Screening allows for the identification for those at higher risk of CKD progression, allowing healthcare providers to implement more aggressive medical therapy to help reduce that risk of progression.

DD: We were very surprised to see that only about 70 percent of those with T2D and CKD were using any kind of glucose-lowering medicine. Should that number be higher?

Dr. Pantalone: Ideally, most patients should be receiving a glucose-lowering medication, although some patients who have T2D can be managed through lifestyle modification alone and may not necessarily require glucose-lowering therapy to control their blood sugar.

Given the progressive nature of T2D, most patients will ultimately require pharmacological therapy to control their blood sugar, with many patients requiring multiple therapies that work via different mechanisms to control their blood sugar.

DD: Only about 8 percent of those with T2 and CKD saw a nephrologist, and 9 percent saw an endocrinologist. Should those numbers be higher?

Dr. Pantalone: There are not enough nephrologists or endocrinologists to manage the ever-expanding populations of patients with CKD, T2D, or both.

Generally, patients are referred to specialists later in the course of disease. By that time, in many instances, the damage has already occurred. While milder cases of CKD and T2D can often be effectively managed by primary care providers, patients with more advanced disease need to be identified through screening and referred to specialists for further evaluation and management.

DD: Are some of the more important medications too expensive for most patients?

Dr. Pantalone: While we have certainly seen some improvement over the past few years in terms of the utilization of SGLT-2 inhibitors in patients with CKD, both with and without T2D, they remain grossly underutilized.

It is important to highlight that the underutilization of therapies that have been shown to reduce the risk of CKD progression is not simply an issue related to the cost of medication, as even ACE inhibitors (ACE-i) or angiotensin II receptor blockers (ARBs), both of which are cheap and have been demonstrated to reduce the risk of CKD progression, are underutilized. There is still a tremendous opportunity for improvement in terms of ensuring our patients are receiving the appropriate therapies.

DD: The Cleveland Clinic is nationally renowned — are these results generalizable for the rest of the country? Can you speculate if other health systems would have better or worse results?

Dr. Pantalone: This is not an issue that is unique to Cleveland Clinic. There is a tendency for patients with chronic medical conditions to experience therapeutic inertia, i.e., the failure to advance (or sometimes de-intensify) medical therapy when appropriate to do so. This happens not only at large academic health centers, but also in small community-based medical practices. Patients are becoming ever more complex and have many comorbidities that require management.

DD: Why is diagnosing and treating CKD early so important?

Dr. Pantalone: Treating patients with type 2 diabetes (T2D) early and aggressively, to lower A1C, has been shown to reduce the risk of developing CKD, and to reduce the risk of progression of existing CKD.

Once a patient develops CKD, there is no “turning back the clock.” You cannot undo the complications of T2D once they develop, it is all about prevention. Once patients do develop CKD … the focus must be on identifying those at a high risk of progression. We must not only control the patient’s blood pressure and blood sugar, but also initiate therapies that have been demonstrated to slow the progression of CKD.


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