New ADA/KDIGO Consensus Guidelines for the Treatment of Diabetes with Chronic Kidney Disease
The American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO) have published new consensus guidelines on the treatment of individuals with diabetes and chronic kidney disease. The report, jointly published in Diabetes Care (de Boer et al., p. 3075) and Kidney International, sets out seven consensus statements, and it means that treatment guidelines are now broadly aligned between the two organizations. “We’re fortunate in 2022 to have multiple effective interventions to prevent and treat kidney disease in diabetes, grounded in strong evidence from rigorous randomized controlled trials,” said lead author Ian de Boer. “Not surprisingly, the ADA and KDIGO individually issued very similar recommendations based on this evidence.” With a major focus on comprehensive care to prevent progression of kidney disease and cardiovascular disease, the report highlights the use of diabetes medications to achieve these aims in the context of diabetes. Specifically, it focuses on optimal use while also controlling glycemia and minimizing other diabetes complications. The authors focus on three relatively new drug classes to achieve the disease management goals: sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and the even newer finerenone, a nonsteroidal mineralocorticoid receptor antagonist. They also look at how these newer drugs can be used in the context of more established drugs such as metformin and renin-angiotensin system inhibitors such as ACE inhibitors or angiotensin II receptor blockers. The new guidelines also include recommendations relating to nutrition, diet, physical exercise, diabetes technologies, and screening/diagnosis and specifically look at the need for a comprehensive care plan. Commenting further, Professor de Boer added, “In this first-ever joint statement from the two organizations, we show how well aligned the recommendations are and provide a consensus roadmap for care. What’s most needed now is a concerted effort to identify patients with chronic kidney disease and implement these proven therapies to improve outcomes for our patients.”
Overcoming barriers to management of chronic kidney disease in patients with diabetes.
Overcoming barriers to management of chronic kidney disease in patients with diabetes.
De Boer et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care 2022;45:3075-3090
Regular Islet Autoantibody Testing Identifies (Many) Cases of Misclassified Type 1 Diabetes
Routine islet autoantibody testing in adults with type 1 diabetes can help identify what appears to be a substantial proportion of individuals who are likely misclassified, according to Eason et al. (p. 2844). “Diagnosing type 1 diabetes in adults can be very difficult because type 2 diabetes is so common and clinical features overlap,” said author Angus Jones. “This means that many adults diagnosed and treated as having type 1 diabetes will actually have type 2 or other forms of diabetes. This has led some experts and guidelines to recommend routine islet autoantibody testing at diagnosis of type 1 diabetes in adults, but there is surprisingly little direct evidence for islet autoantibody testing in this group,” he added. The findings come from a prospective analysis of 722 adults with clinically diagnosed type 1 diabetes with a duration of >12 months. The authors looked at the relationship between the status of the three islet autoantibodies, genetic risk scores, clinical characteristics, and disease progression and compared them to those of patients with type 2 diabetes. Just under one-quarter of the participants with diagnosed type 1 diabetes were autoantibody negative. The group also had genetic risk scores and annual changes in C-peptide characteristics that were substantially lower than those for antibody-positive type 1 diabetes. They also found that just over one-third of the autoantibody-negative group changed treatment after receiving their results, with some discontinuing insulin or adding agents to insulin. “Our findings suggest that a large proportion of adults diagnosed with type 1 diabetes who have negative islet antibodies are likely to have other causes of their diabetes, and that routine testing and feedback of results is associated with change in treatment,” said Dr. Jones. “This supports recent recommendations for routine islet antibody testing in adults newly diagnosed with type 1 diabetes and very careful consideration of other forms of diabetes if islet autoantibodies are negative.”
Violin plot of type 1 diabetes genetic risk scores for participants with type 1 diabetes and autoantibody negative (left), type 1 diabetes and autoantibody positive (center), and type 2 diabetes and autoantibody negative (right).
Violin plot of type 1 diabetes genetic risk scores for participants with type 1 diabetes and autoantibody negative (left), type 1 diabetes and autoantibody positive (center), and type 2 diabetes and autoantibody negative (right).
Eason et al. Routine islet autoantibody testing in clinically diagnosed adultonset type 1 diabetes can help identify misclassification and the possibility of successful insulin cessation. Diabetes Care 2022;45:2844-2851
Comprehensive Diabetes Management Program RAMP-DM Continues to Be a Success at 10 Years
Further analysis from the Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) (Tang et al., p. 2871) suggests that it has achieved significant reductions in diabetes-related complications and all-cause mortality at 10 years of follow-up. Previously the program reported (https://doi.org/10.2337/dc17-0426) reductions in complications and mortality at 5 years of follow-up. “We have provided real-world evidence for the feasibility and effectiveness of comprehensive risk assessment and management care models such as RAMP-DM, which are sustainable in people with diabetes,” said author Carlos K.H. Wong. “The primary care setting is well placed to provide high-quality and accessible diabetes care.” The authors do note, however, that the long-term cost-effectiveness of the program is still to be assessed. The study is based on a cohort of adult patients with type 2 diabetes who were managed in the Hong Kong primary care system in 2009 and 2010. Diabetes patients received usual care with additional risk-stratified personalized care based on RAMPDM and were matched with propensity scoring one to one with patients who received only usual care. A total of 36,746 patients (18,373 patients in each group) were included in the main analysis. After a median of 9.5 years, individuals in the RAMP-DM group had significantly lower risks for macrovascular and microvascular complications and all-cause mortality. These ranged from 42% to 55% risk reductions compared to only usual care. The reduction in risk for mortality in the RAMP-DM group persisted to 10 years of follow-up, while risk of developing complications was attenuated at 8–9 years. In terms of disease control parameters, RAMP-DM participants had better control of HbA1c and blood pressure, among others, compared to the usual care group. Commenting further, author Cindy L.K. Lam said, “We hope our results will encourage the integration of comprehensive risk assessment and management into routine primary diabetes care as a strategy to prevent disability and to relieve the burden on public health care systems caused by diabetes.”
Kaplan-Meier survival curves for any diabetes-related complication. Lines show usual care only (blue) and usual care plus RAMP-DM (red).
Kaplan-Meier survival curves for any diabetes-related complication. Lines show usual care only (blue) and usual care plus RAMP-DM (red).
Tang et al. Ten-year effectiveness of the multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on macrovascular and microvascular complications and all-cause mortality: a population-based cohort study. Diabetes Care 2022;45: 2871-2882
25 Years of Experience: How Data Helped Improve Scottish Diabetes Outcomes
Linked data and health informatics have helped improve the quality of diabetes care in the Tayside region of Scotland over the past 25 years, according to Siddiqui et al. (p. 2828). Charting their experience all the way back to the St. Vincent Declaration in October 1988, they describe the development of highly linked-up data systems and how they appear to have helped improve health outcomes for patients with diabetes. What emerges is a picture of a centralized electronic medical record that captures (nearly) all relevant patient data for (nearly) all patients in the Tayside region and beyond. They also describe the extensive research that has been enabled through the data linkage that has been achieved over the years. They illustrate the implementation of clinical decision support and patient portal systems and how this has helped lower the rates of misdiagnosed type 1 diabetes and how the use of diabetes technologies has improved glycemic control. They also describe how retinal photography, and its gradual digitization, has managed to deliver declines in rates of retinopathy. One particular outcome in that area is the marked improvements (i.e., reductions) in rates of retinopathy in rural areas. They also detail how foot screenings, ulceration, and amputations have changed over the years, again delivering notable improvements in outcomes. While the data sets have evidently provided insights into numerous aspects of diabetes, the authors point out that the potential to improve clinical care remains huge and largely untapped. “This comprehensive clinical tool has also been the foundation for extensive contribution to our understanding of the causes and consequences of diabetes,” they write. “Yet with the increasing availability of data and the exponential growth of computational performance and data science, it seems likely that we are just at the beginning of the journey.”
Number of individuals per year (1994–2021) living with type 1 or type 2 diabetes in the Tayside region of Scotland.
Number of individuals per year (1994–2021) living with type 1 or type 2 diabetes in the Tayside region of Scotland.
Siddiqui et al. Using data to improve the management of diabetes—the Tayside experience. Diabetes Care 2022;45:2828-2837