This compendium provides an important and timely update for clinicians, reviewing many important considerations for improving clinical outcomes in patients with type 2 diabetes and chronic kidney disease (CKD). It is important to remember that, from an epidemiological standpoint, people with type 2 diabetes and CKD are much more likely to suffer from cardiovascular events than they are to reach end-stage renal disease. In fact, they are five times as likely to succumb from cardiovascular disease than to require renal replacement therapy. With improved opportunities to identify patients earlier in their course of disease and those with increased risk factors for progression, we may be in a better position than ever to implement primary rather than only secondary prevention strategies.
Unfortunately, most of the available data in this arena are from clinical trials focusing on secondary prevention in patients who have already lost more than half of their original kidney function. In large part, secondary prevention studies have been the norm because these studies tend to be shorter and more cost-effective for providing the hard endpoints needed for regulatory approval with specific indications. On the other hand, in clinical practice, primary prevention is a much more important opportunity to make a substantial difference in the quality and duration of our patients' lives. We therefore hope this compendium will be important to readers, not only by describing more precise, evidence-based approaches for disease progression mitigation, but also by helping them adopt and optimally implement both traditional and newer therapeutic options to improve clinical outcomes. Additionally, we hope this opportunity to understand more about risk factors, biomarkers, and phenotyping of patients who are more likely to exhibit kidney disease progression will encourage readers to focus not only on secondary intervention, but also on primary prevention of CKD in their patients with diabetes.
Toward that end, our focus for patients with diabetes and CKD should be on earlier identification, education, and intervention using guidelines-based and carefully individualized approaches. The discussion provided by Dr. Keith C. Norris (p. 19) about the need to correct disparities in clinical care is also a particularly important consideration for diabetic kidney disease treatment. So, too, is the current conversation about the potentially deleterious effect of modifying GFR estimation equations based on patients' race and whether this practice should be halted to reduce bias and inequities in the timely provision of appropriate treatment.
In the meantime, it is encouraging that we now have more therapeutic opportunities. Moving forward, it will be important for our patients to have access to newer therapies and the ability to avoid the pitfalls of prescription regimens that require substantial out-of-pocket copayments and laborious prior authorizations. We hope readers will find the data and practical strategies presented throughout this compendium helpful in their clinical practice and that they will appreciate and embrace the wealth of new clinical options to improve the health and lives of their patients with type 2 diabetes and CKD.
The opinions expressed are those of the authors and do not necessarily reflect those of AstraZeneca, Bayer, or the American Diabetes Association. The content was developed by the authors and does not represent the policy or position of the American Diabetes Association, any of its boards or committees, or any of its journals or their editors or editorial boards.
Editorial and project management services were provided by Debbie Kendall of Kendall Editorial in Richmond, VA. M.R.W. is supported by National Institutes of Health grants R01 HL-127422, U01 DK-16095-01, U01 DK-106102, and R01 DK-120886. R.A. is supported by National Heart Lung and Blood Institute grant R01 HL126903 and U.S. Veterans Administration grant I01 CX001753. P.R. is supported by Novo Nordisk Foundation grant PROTON Personalized Treatment of Diabetic Nephropathy (NNF14OC0013659).
Dualities of Interest
M.R.W. has served on a clinical trial steering committee for Vifor and on advisory boards for AstraZeneca, Boehringer Ingelheim, Janssen, Merck, Novo Nordisk, and Vifor.
R.A. has received consulting fees from Akebia, AstraZeneca, Bayer, Boehringer Ingelheim, Chinook, Diamedica, Merck, Reata, Relypsa, and Sanofi and has received royalties from UpToDate.
P.R.'s institution has received honoraria from his teaching and consultancy activities from Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Gilead, Merck, Merck, Sharp, & Dohme, Mundipharma, Novo Nordisk, Sanofi, and Vifor.
J.B. serves as a consultant for Abbott, Adrenomed, Amgen, Array, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squib, CVRx, G3 Pharmaceutical, Impulse Dynamics, Innolife, Janssen, LivaNova, Luitpold, Medtronic, Merck, Novartis, Novo Nordisk, Relypsa, Roche, V-Wave Limited, and Vifor.
K.C.N. has been a consultant to Atlantis Health Care, served on an advisory board for ESRD Network 3, and been a board member of the Forum of ESRD Networks.
S.D.-J. has received research grants from the National Institutes of Health, and his institution has received funding for clinical trials in which he was an investigator from AstraZeneca, Boehringer Ingelheim, and Novo Nordisk; he has served as a consultant or advisory board member for AstraZeneca, Bayer, Boehringer Ingelheim, Janssen, Merck, and Sanofi; and he is a stock shareholder in Aerami Therapeutics and Jana Care.
G.L.B. has been a consultant to Alnylam, AstraZeneca, Bayer, Ionis, KBP Biosciences, Merck, and Vifor and has served on clinical trial steering committees for Bayer, Novo Nordisk, and Vascular Dynamics.
No other potential conflicts of interest relevant to this compendium were reported.
All authors researched and wrote their respective sections. Lead author M.R.W. reviewed all content and is the guarantor of this work.