Diabetes, Chronic Kidney Disease and Special Populations
Diabetes and chronic kidney disease (CKD) are global public health problems. In the United States, the burden of diabetes and CKD is borne disproportionately by ethnic and racial minorities. 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 racial minorities, is crucial to achieving positive outcomes in these highly susceptible groups. Recommendations from the National Kidney Foundation (NKF) 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.
- 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.
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.