Special ReportDiabetic Kidney Disease: A Report From an ADA Consensus Conference
Section snippets
Laboratory Assessment of DKD
Identifying and monitoring DKD relies upon assessments of kidney function, usually with an estimated GFR (eGFR) < 60 mL/min/1.73 m2, and kidney damage, usually by estimation of albuminuria > 30 mg/g creatinine. Widespread utilization of these simple laboratory measures has facilitated earlier recognition of DKD and has formed the basis for clinical staging. However, understanding the imprecision associated with these tests is critical to their appropriate utilization in clinical care.
Limitations of eGFR
Routine
Cardiovascular Risks of DKD
Among patients with diabetes, those with kidney disease are consistently observed to have substantially elevated mortality rates.26 Much of this mortality is due to CVD, although noncardiovascular mortality is also increased. Albuminuria and eGFR are independently and additively associated with increased risks of CVD events, CVD mortality, and all-cause mortality.26 Both diabetes and CKD have been observed to have incidence rates of CVD events similar to patients with established coronary heart
Hypertension
Based on the most recent Joint National Committee (JNC) 8 and KDIGO guidelines, BP levels in diabetes are recommended to be below 140/90 mm Hg38, 39 in order to reduce CVD mortality and slow CKD progression. The support for these BP levels is derived from a limited number of randomized trials among patients with diabetes with a focus on CVD event outcomes. However, there are no randomized controlled trials of BP levels that examine CKD events. The data that support the BP level of < 140/90 mm Hg to
Glycemia Measurement
HbA1c has limitations in the general population and is even less precise in the setting of DKD.61 In the typical 120-day life cycle of a red blood cell, the HbA1c reflects time-averaged exposure to glucose. Accelerated red blood cell turnover is a major cause of imprecision of HbA1c. Erythrocyte survival times become shorter as eGFR falls, resulting in lower HbA1c. Glycation rate can also be influenced by temperature, acid-base balance, and hemoglobin concentration.62 Onset of anemia associated
Nutritional Therapy
For the goals of reducing DKD onset and progression, approaches to nutritional therapy are a subject of much debate. Extensive discussion of dietary management in diabetes and obesity is beyond the scope of this review. Instead, the focus is on extremes of macronutrient intake that have been associated with adverse outcomes, followed by assessment of concepts for healthful eating that are supported by clinical evidence relevant to DKD. It is well recognized that very low-protein diets can lead
Risks of Hypertension and DKD
Historically, it was assumed that diabetes complications primarily affected adults with long-standing and/or poorly controlled disease and spared children with recent-onset disease. A paucity of clinical research in the pediatric population perpetuated this assumption. However, recent studies contradict those tenets and paint a remarkably different picture. The multicenter Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study prospectively evaluated the incidence,
Multidisciplinary Approaches for Comprehensive Care
Optimal care for patients with DKD is complex and best managed using comprehensive multifactorial risk-reduction strategies.160, 161 There is a growing consensus that patient outcomes are most improved with simultaneous control of BP, glucose, and lipids; use of antiplatelet agent therapy when indicated; and lifestyle modifications that include smoking cessation, a healthy diet, exercise, and weight reduction among those who are overweight or obese.4, 20 Smoking is associated with progressive
Conclusions
DKD has emerged as a major aftermath of the worldwide diabetes pandemic. Therefore, diabetes prevention must remain at the cornerstone of reducing DKD. Identification of DKD depends upon screening for increased albuminuria and low eGFR. Both measurements have considerable imprecision, highlighting the need for better identification methods, especially for people at high risk of DKD complications. Prevention of CVD, a major cause of death in DKD, centers upon management of LDL cholesterol and
Acknowledgments
The American Diabetes Association (ADA) thanks Drs Tuttle and Molitch for serving as co-chairs for the Consensus Conference on Chronic Kidney Disease and Diabetes, held March 20-22, 2014. ADA also thanks the ASN (Tod Ibrahim, Phillip Kokemueller, Uptal D. Patel [liaison]), and the NKF (Emily Howell, Kerry Willis, George L. Bakris [liaison]) for participating in the conference as collaborators. The authors thank ADA staff members Erika Gebel Berg, PhD, for significant editorial contributions and
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This article is being published concurrently in Diabetes Care and AJKD. The articles are identical except for stylistic changes in keeping with each journal’s style. Either of these versions may be used in citing this article.