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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 2  |  Page : 217-221
Diabetic kidney disease: Act now or pay later

1 Department of Epidemiology and Preventive Medicine, Monash University, Australia
2 Baker IDI Heart and Diabetes Institute, 2500 Kooyong Road, Caulfield. VIC 3162, Australia

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Date of Web Publication9-Mar-2010

How to cite this article:
Atkins RC, Zimmet P. Diabetic kidney disease: Act now or pay later. Saudi J Kidney Dis Transpl 2010;21:217-21

How to cite this URL:
Atkins RC, Zimmet P. Diabetic kidney disease: Act now or pay later. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2021 Dec 8];21:217-21. Available from: https://www.sjkdt.org/text.asp?2010/21/2/217/60056

For the 2010 International Society of Nephrology/International Federation of Kidney Foundations World Kidney Day Steering CommitteeFNx01 (RA) and the International Diabetes Federation (PZ) World Kidney Day 11 March 2010: we must act on diabetic kidney disease

   Introduction Top

In 2003, the International Society of Nephro­logy and the International Diabetes Federation launched a booklet called "Diabetes in the Kidney: Time to act [1]" to highlight the global pandemic of type 2 diabetes and diabetic kid­ney disease. It aimed to alert governments, health organizations, providers, doctors, and pa­tients to the increasing health and socio-eco­nomic problems due to diabetic kidney disease and its sequelae, end-stage kidney disease re­quiring dialysis, and cardiovascular death. Se­ven years later, the same message has become even more urgent. World Kidney Day 2010, under the auspices of the International Society of Nephrology (ISN) and the International Fe­deration of Kidney Foundations IFKF), toge­ther with the International Diabetes Federation (IDF), provides yet another chance to under­line the importance of diabetic kidney disease, stress its lack of awareness at both public and government levels and emphasize that its ma­nagement involves prevention, recognition, and treatment of its complications. Primary preven­tion of type 2 diabetes will require massive lifestyle changes in the developing and deve­loped world supported by strong governmental commitment to promote lifestyle and societal change.

   The Global Threat of Type 2 Diabetes Top

The 21st century has the most diabetogenic environment in human history. [2],[3] Over the past 25 years or so, the prevalence of type 2 diabe­tes in the USA has almost doubled, with three­to five-fold increases in India, Indonesia, China, Korea and Thailand. [4] In 2007, there were 246 million people with diabetes in the world, but by 2025, that number is estimated to reach 380 million. [5] People with impaired glucose tole­rance, a "prediabetic state" numbered 308 mil­lion in 2007 and will increase to 418 million by 2025. [5] The increase in prevalence of diabetes will be greater in the developing countries. In Mexico for example, 18% of its adult popu­lation will suffer from type 2 diabetes by 2025. According to the WHO, China and India will have about 130 million diabetics by 2025 who will consume about 40% of their country's health care budget in addition to reducing pro­ductivity and hindering economic growth.

It was against this background that on De­cember 21 st 2006, the United Nations General Assembly unanimously passed Resolution 61/ 225 declaring diabetes an international public health issue and identifying World Diabetes Day as a United Nations Day, only the second disease after HIV/AIDS to attain that status. For the first time, governments have acknow­ledged that a non-infectious disease poses as serious a threat to world health as infectious diseases like HIV/AIDS, tuberculosis, and ma­laria. The problems of diabetes are now seen as a major global public health concern, espe­cially in the developing world that can hardly afford it. The first step to act on diabetic kid­ney disease must encompass public health cam­paigns aimed at preventing the development of type 2 diabetes.

   Diabetic Kidney Disease Top

Diabetes is now the major cause of end-stage renal disease (ESRD) throughout the world in both developed and emerging nations. [6] It is the primary diagnosis causing kidney disease in 20-40% of people starting treatment for ESRD worldwide. [7] In Australia, new type 2 diabetes patients starting dialysis increased 5-fold bet­ween 1993 and 2007. [8] In Japan, there has been a 7-fold increase in new patients starting renal replacement therapy because of diabetes, ac­counting for 40% of all new incidence pa­tients, between 1983 and 2005. [9] Thus, some 30% of the predicted 1.1 trillion dollar medical costs of dialysis world-wide during this decade will result from diabetic nephropathy. [10]

In the United Kingdom Prospective Diabetes Study (UKPDS), the rates of progression of newly diagnosed type 2 diabetics between the stages of normoalbuminuria, microalbuminu­ria, macroalbuminuria and renal failure were 2-3% per year. [11] Over a median of 15 years of follow-up of 4,000 participants, almost 40% developed microalbuminuria. [12] In the DEMAND study of 32,208 people from 33 countries with known type 2 diabetes attending their family doctor, 39% had microalbuminuria and preva­lence increased with age, duration of diabetes and presence of hypertension. [13] About 30% of the UKPDS cohort developed renal impairment, of which almost 50% did not have preceding albuminuria. [12] Reduced glomerular filtration rate and albuminuria caused by diabetic neph­ropathy are independent risk factors for cardio­vascular events and death. [14] Therefore, a stra­tegy to detect early diabetic kidney disease by screening for albuminuria as well as reduced glomerular filtration rate is the second step in taking action on diabetic kidney disease.

An added difficulty to overcome is the remar­kable lack of awareness among patients about their condition. In population-based surveys, for every known diabetic patient, there is at least one more that is unknown; [15] only 8.7% of the general population were able to identify diabetes as a risk factor for kidney disease. [16] For patients with diabetic kidney disease, very few are aware of their condition with some community surveys putting patient awareness of their disease as low as 9.4%, particularly in those with milder impairment. [17] Thus, public education is the third step required for acting on diabetic kidney disease in the community. The IFKF has a long-term goal for all kidney patients world-wide to not only be aware of their disease, but to actively know for example their blood pressure and the treatment objec­tives.

   Management of Diabetic Kidney Disease Top

There is little use in screening populations or "at risk" groups unless follow-up is undertaken and effective treatment is initiated and asse­ssed. [18] Fortunately, there is evidence that early therapeutic intervention in patients with chronic kidney disease or diabetes can delay onset of complications and improve outcomes. For exam­ple, the UKPDS, [19],[20] STENO-2, [21] and AD-VANCE studies [22],[23],[24] all demonstrated that tight control of blood glucose level, blood pressure (and lipids in STENO-2) significantly reduced incidence and progression of diabetic kidney disease. In people with type 2 diabetes, inhi­bition of the renin-angiotensin-aldosterone sys­tem using an ACE inhibitor or an ARB de­creased the progression from normoalbuminu­ria to microalbuminuria, [25] reduced the progre­ssion from micro albuminuria to macroalbu­minuria, [26] and slowed the development of ESRD. 27 Thus the use of an Angiotensin con­verting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) is now a standard the­rapy for patients with diabetic nephropathy as well as glucose, lipid, and blood pressure con­trol. Effective management using evidence­based therapies is the fourth step in tackling diabetic kidney disease.

The fifth step is development of new thera­pies. Many new agents are now in clinical trials to reduce renal damage and fibrosis, including blockade of formation of advanced glycation end-products and other signaling pathways. Other novel agents may potentially prove to be effective in large randomized double-blind cli­nical trials. [28]

   How can we Act Now? Top

The steps to be taken are clear: campaigns aimed at (1) prevention of type 2 diabetes; (2) screening for early diabetic kidney disease; (3) increasing patient awareness of kidney disease; (4) using medications of proven strategy and finally (5) researching and trialing of new the­rapies. The ultimate challenge is to get action from primary health care to all higher levels; from the individual patient, to those at risk, in various health jurisdictions, in all countries des­pite varying economic circumstances and prio­rities. The problem is a global one and yet re­quires action at a local level; prevention, scree­ning, and treatment strategies; education, in­cluding increasing awareness both in diabetic patients and those at risk of developing diabe­tes; and health priorities of governments. Basic research and clinical trials searching for a new understanding and therapies must be supported.

The United Nations, as noted earlier, recog­nized the importance of diabetes in 2006 by establishing a World Diabetes Day. Both the ISN and the International Diabetes Federation are working closely with WHO to provide in­creasing understanding of the challenge that diabetic kidney disease poses to world health and health care budgets. However, World Kid­ney Day also provides a focus for other inter­national agencies, government ministries of health, non-government organization, founda­tions and academic institutions to come toge­ther with national kidney foundations to be in­volved in the effort to prevent and manage diabetic kidney disease.

The ISN through it's COMGAN Research and Prevention Committee has developed a web­based program, the KHDC (for detection and management of chronic kidney disease, hyper­tension, diabetes and cardiovascular disease in developing countries ( http://www.nature.com/ isn/education/guidelines/isn/pdf/ed_051027_2 x1.pdf ) as a global template involving a detec­tion management and data assessment program, which has so far screened some 42,000 people in 25 developing countries and the data are being stored and analyzed at the Kidney Disease Data Center at the committee headquarters at the Mario Negri Institute in Bergamo, Italy. This program can be tailored to any individual country's needs and resources. The IFKF also has a program initiated by the National Kidney Foundation in the USA called the Kidney Early Evaluation Program (KEEP) which is a scree­ning program for people at high risk of kidney disease. KEEP has now been implemented in many countries and will again screen and ma­nage patients with diabetic kidney disease.

The focus on diabetic kidney disease for World Kidney Day 2010 brings awareness of the mag­nitude of the problem and ramifications for glo­bal health of people with diabetes and kidney disease. It is therefore time to act and act ur­gently. It is time for strategies that prevent dia­betes and its sequelae. It is time for programs for health care workers to diagnose and treat people with diabetic kidney disease. It is time for governments to pass legislation to enable the diabetes pandemic to be controlled. After all, diabetic kidney disease, like the epidemics of infectious diseases that have long domina­ted public health agendas, is potentially pre­ventable. Indeed, March 11, 2010 is time to act on diabetic kidney disease and to sustain that action long after World Kidney Day.

ISN/IFKF 2010 World Kidney Day Steering Committee : William G Couser, MD, Miguel Riella MD, Co-chairpersons. Georgi Abraham MD, Paul Beerkens, John Feehally MD, Guil­ lermo Garcia-Garcia MD, Dan Larson, Philip KT Li MD, Bernardo Rodriguez-Iturbe, MD

   Acknowledgement Top

The authors would like to acknowledge Dr. Anne Reutens contributions to the manuscript.

   References Top

1.International Diabetes Federation and Inter­national Society of Nephrology, Diabetes and kidney disease: time to act. 2003: Brussels.  Back to cited text no. 1      
2.Zimmet P, Alberti K, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414:782-7.  Back to cited text no. 2      
3.King H., Aubert R, Herman W. Global burden of diabetes, 1995-2025: Prevalence, numerical estimates, and projections. Diabetes Care 1998; 21:1414-31.  Back to cited text no. 3      
4.Yoon KH, Lee JH, Kim JW, et al. Epidemic obesity and type 2 diabetes in Asia. Lancet 2006;368(9548):1681-8.  Back to cited text no. 4      
5.Sicree R, Shaw J, Zimmet P. Diabetes and impaired glucose tolerance., in Diabetes Atlas, 3rd edition, Gan D, (Ed). 2006, International Diabetes Federation: Brussels. p. 15-109.  Back to cited text no. 5      
6.Reutens AT, Prentice L, Atkins R. The Epide­miology of Diabetic Kidney Disease, in The Epidemiology of Diabetes Mellitus, 2nd Edi­tion, Ekoe J. Ed. 2008, John Wiley& Sons Ltd: Chichester. p. 499-518.  Back to cited text no. 6      
7.National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. International comparisons, in 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. 2007, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases: Bethesda. p. 239-54.  Back to cited text no. 7      
8.Appendix II, in ANZDATA Registry Report 2008, McDonald S, Excell L, Livingston B, Eds. 2008, Australia and New Zealand Dialysis and Transplant Registry: Adelaide. p. 1-97.  Back to cited text no. 8      
9.Yamagata K, Iseki K, Nitta K, et al. Chronic kidney disease perspectives in Japan and the importance of urinalysis screening. Clin Exp Nephrol 2008;12(1):1-8.  Back to cited text no. 9      
10.Lysaght M. Maintenance dialysis population dynamics: Current trends and long term impli­cations. J Am Soc Nephrol 2002;13:S37-40.  Back to cited text no. 10      
11.Adler AI, Stevens RJ, Manley SE, et al. Deve­lopment and progression of nephropathy in type 2 diabetes: The United Kingdom Prospec­tive Diabetes Study (UKPDS 64). Kidney Int 2003;63(1):225-32.  Back to cited text no. 11      
12.Retnakaran R, Cull CA, Thorne KI, et al. Risk factors for renal dysfunction in type 2 diabetes: UK Prospective Diabetes Study 74. Diabetes 2006;55(6):1832-9.  Back to cited text no. 12      
13.Parving HH, Lewis JB, Ravid M, et al. Preva­lence and risk factors for microalbuminuria in a referred cohort of type II diabetic patients: A global perspective. Kidney Int 2006;69(11): 2057-63.  Back to cited text no. 13      
14.Ninomiya T, Perkovic V, de Galan BE, et al. Albuminuria and kidney function indepen­dently predict cardiovascular and renal out­comes in diabetes. J Am Soc Nephrol 2009;20 (8):1813-21.  Back to cited text no. 14      
15.Dunstan DW, Zimmet PZ, Welborn TA, et al. The rising prevalence of diabetes and impaired glucose tolerance: the Australian Diabetes, Obesity and Lifestyle Study. Diabetes Care 2002;25(5):829-34.  Back to cited text no. 15      
16.White SL, Polkinghorne KR, Cass A, et al. Limited knowledge of kidney disease in a survey of Aus Diab study participants. Med J Aust 2008;188(4):204-8.  Back to cited text no. 16      
17.Whaley-Connell A, Sowers JR, McCullough PA, et al. Diabetes mellitus and CKD aware­ness: the Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES). Am J Kidney Dis 2009;53(4 Suppl 4):S11-21.  Back to cited text no. 17      
18.Thomas M, Viberti G, Groop P. Screening for chronic kidney disease in patients with dia­betes: Are we missing the point? Nat Clin Pract Nephrol 2008;4(1):2-3.  Back to cited text no. 18      
19.Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359(15):1577-89.  Back to cited text no. 19      
20.Bilous R. Microvascular disease: What does the UKPDS tell us about diabetic nephropathy? Diabetes Med 2008;25(Suppl2):25-9.  Back to cited text no. 20      
21.Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial inter­vention on mortality in type 2 diabetes. N Engl J Med 2008;358(6):580-91.  Back to cited text no. 21      
22.Patel A; ADVANCE Collaborative Group, MacMahon S, et al. Effects of a fixed combi­nation of perindopril and indapamide on mac­rovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet 2007;370(9590):829-40.  Back to cited text no. 22      
23.ADVANCE Collaborative Group, Patel A, MacMahon S, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358(24): 2560-72.  Back to cited text no. 23      
24.Zoungas S, de Galan BE, Ninomiya T, et al. The combined effects of routine blood pressure lowering and intensive glucose control on macrovascular and microvascular outcomes in patients with type 2 diabetes: New results from ADVANCE. Diabetes Care 2009;32(11):2068-74.  Back to cited text no. 24      
25.Ruggenenti P, Fassi A, Ilieva AP, et al. Pre­venting microalbuminuria in type 2 diabetes. N Engl J Med 2004;351(19):1941-51.  Back to cited text no. 25      
26.Parving HH, Lehnert H, Brochner-Mortensen J, et al. The effect of irbesartan on the deve­lopment of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001;345(12): 870-8.  Back to cited text no. 26      
27.Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin­receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Eng J Med 2001;345(12):851-60.  Back to cited text no. 27      
28.Burney B, Kalaitzidis R, Bakris G. Novel therapies of diabetic nephropathy. Curr Opin Nephrol Hypertens 2009;18(2):107-11.  Back to cited text no. 28      

Correspondence Address:
Robert C Atkins
Head of Kidney Diseases Prevention, Department of Epidemiology and Preventive Medicine, Monash University
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