“An ounce of prevention is worth a pound of cure.”
—Benjamin Franklin
The theme of this issue's “From Research to Practice” section(p. 8–36) is diabetic kidney disease (DKD), a more definitive term than “diabetic nephropathy” for the coexistence of chronic kidney disease (CKD) and diabetes. This topic is of profound concern to all diabetes care providers.
The global epidemic of type 2 diabetes has resulted in an alarming increase in the number of patients with CKD, which is now > 0 million people worldwide.1 A cross-sectional analysis of the National Health and Nutrition Examination Surveys (NHANES 1988–1994 and NHANES 1999–2004) was recently published in the Journal of the American Medical Association.2 Analysis of the survey data indicates a high prevalence rate of CKD in the United States. Overall, the prevalence rate of CKD increased from 10.0% in the 1988–2004 period to 13.1% in the 1999–2004 period. This increased prevalence is explained in part by an increase in a number of CKD risk factors, which include an aging population and an increase in the proportion of people with obesity, diagnosed diabetes, and hypertension.2
Diabetes accounts for 4 % of prevalent kidney failure, an increase from 18%in 1980.3 However,the greater concern, despite the growing prevalence of CKD in the United States, is the fact that awareness of CKD remains low, not only in the general population, but also and especially among those directly affected by having CKD. Only 11.6% of men and. % of women in CKD Stage 3 reported being aware of their “weak or failing” kidneys; awareness was only 42% among those in Stage 4 CKD. In addition, prevalence counts for end-stage renal disease (ESRD) continue to rise, particularly for people aged 4–64 years.4 The number of patients treated by dialysis and kidney transplantation in the United States also increased from 209,000 in 1991 to 472,000 in 2004. It is estimated that by 201, there will be 136,000 patients with incident ESRD per year and 712,000 patients with prevalent disease.5 Finally,the number of patients with diabetes as the primary cause of ESRD rose 6.6%between 2001 and 2005.3
CKD and ESRD not only affect a growing number of Americans, but also have an enormous economic impact, both in treatment costs and in terms of lost productivity and increased disability. The U.S. Renal Data System (USRDS) 2007 Annual Data Report states that total Medicare costs related to ESRD in 200 were $21.3 billion and will approach $54 billion by 2020. The USRDS also projects that, with the continued expected growth in the prevalence of diabetes, patients with ESRD resulting from poorly controlled diabetes will account for 47% of the incident ESRD population and 37% of the prevalent population by 2020.4
A recent article in The Wall Street Journal reported on the current shortfall of donor kidneys for transplantation, in the context of an increasing debate over the sale of live donor kidneys in the United States.6 The article noted that almost 7,000 patients are on the waiting list for a cadaver kidney transplant, which is nearly a fivefold increase since 1988. Last year, about 10,600 cadaver donor kidneys were available for transplantation; the average wait for a transplant in the United States now is 5–6 years. The article acknowledged that the increased demand for transplants has been “fueled partly by higher rates of diabetes,” but mentioned nothing about how improvements in both glycemic and blood pressure control could potentially reduce the burden of CKD and ESRD and the eventual need for renal replacement therapies. Given the tremendous impact of CKD and ESRD in financial and quality-of-life terms, how much of this is preventable and avoidable?
In early CKD (Stages 1 and 2), microalbuminuria exceeds macroalbuminuria by a ratio of about 9 to 1.2 It has been well established that both aggressive blood pressure control and blood glucose control can dramatically reduce the progression of CKD in diabetes. So, why are such evidence-based measures not being practiced more extensively, given the alarming statistics presented above? Part of the answer lies in the fact that much of the care of early stage CKD is provided by primary care physicians (PCPs) whose practices are largely compensated in an acute care model environment. They do not have the time or the support to realistically manage such a complex condition.
Comprehensive, aggressive, and earlier care of CKD demands the resources of a team to achieve any reversal of the trends noted above. Diabetes care teams should include nurse practitioners, clinical pharmacists, dietitians, and diabetes educators redeployed from diabetes education programs to assist PCPs in managing this complex condition. These health professionals can function under protocols approved by nephrologists and PCPs to implement medication changes to slow the progression of CKD.
This strategy could work very well in organized health care systems, but the greater challenge remains in the broader communities where PCPs function in small groups apart from heath care systems and in rural areas. In such cases, a referral system needs to be established where PCPs' fears of losing patients to specialists must be addressed. Unconventional solutions will be required if there is any reasonable hope to contain the growing epidemic of CKD and its tragic consequences.
Roger P. Austin, MS, RPh, CDE, is a clinical pharmacy specialist at Henry Ford Health System in Detroit, Mich. He is an associate editor ofDiabetes Spectrum.
