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Long-term Impact of Diabetes and the Importance of Optimal Management

This learning resource provides clinical guidance on chronic kidney disease in people with type 2 diabetes, highlighting the importance of optimal management for long-term outcomes. It covers the natural history of type 2 diabetes, microvascular and cardiovascular complications, and the risk of kidney failure. Interventions, such as intensive blood glucose control, are also discussed.

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Long-term Impact of Diabetes and the Importance of Optimal Management

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  1. Long-term impact of diabetes and the importance of optimal management of the condition Section B

  2. Objectives and background for this learning resource Introduction: This learning resource has been developed as part of a medical education initiative supported by Janssen. The content of this slide kit has been developed by an advisory board of renal physicians, GPs and specialist nurses. The panel of experts includes members of the British Renal Society Chronic Kidney Disease (CKD) Strategy Group. Bedrock Healthcare, a medical communications agency, has provided editorial support in developing the content; Janssen has reviewed the content for technical accuracy. Educational objectives: • To provide clear and applicable clinical guidance on chronic kidney disease (CKD) in people with type 2 diabetes to primary care healthcare professionals • To advise primary healthcare professionals on what people with diabetes need to know about their own condition with relation to CKD Usability objectives: • To provide essential, relevant and up to date information in concise presentations • To enable primary healthcare professionals to locate, select and use the content of the learning resource, as appropriate to their needs • To enable secondary care experts in CKD to refer their primary care colleagues tothe resource

  3. Contents overview This learning resource comprises the following 10 sections (A-E):

  4. Contents overview (cont.) This learning resource comprises the following 10 sections (F-J):

  5. Section B – 3 key learning objectives • Type 2 diabetes is a progressive chronic disease requiring long-term monitoring and intervention • Sub-optimal treatment is associated with poor outcomes, including: • Microvascular complications • Cardiovascular complications • Premature death • By controlling blood glucose and blood pressure, these complicationsmay be preventable

  6. The natural history of type 2 diabetes increases the riskof microvascular and cardiovascular complications Microvascular complications include: • Kidney damage1 • Eye damage1 • Nerve damage1 Cardiovascular complications include: • Coronary artery disease (leading to heart attacks, angina)1 • Peripheral artery disease(leg claudication, gangrene)1 • Carotid artery disease (strokes, dementia)1 Type 2diabetes • Functionalchanges* Risingcreatininelevels End stagekidney disease Cardiovasculardeath Albuminuria • Structuralchanges† Risingbloodpressure * Renal haemodynamics altered, glomerular hyperfiltration † Glomerular basement membrane thickening , mesangial expansion , microvascular changes +/- References: 1.NICE clinical guideline 87. The management of type 2 diabetes. Issued: May 2009 last modified: July 2014.

  7. Untreated diabetic kidney disease can lead tokidney failure Without specific interventions, 20-40% of people with type 2 diabetes and albuminuria progress to overt kidney disease1 Adapted from: NKF K/DOQI Guidelines. Am J Kidney Dis. 2004 May;43(5 Suppl 1):S1-290. Relationship of stage of kidney disease and level of albuminuria to prognosis in CKD2 Vertical axis (Risk) shows hypothetical risks for adverse outcomes of CKD, such as progression to kidney failure or onset of cardiovascular disease Adapted from: American Diabetes Association. Diabetes Care 2004;27(suppl 1):s79-s83. References: 1. American Diabetes Association. Diabetes Care 2004;27(suppl 1):s79-s83. 2. NKF K/DOQI Guidelines. Am J Kidney Dis. 2004 May;43(5 Suppl 1):S1-290.

  8. Prevalence of kidney disease increases over timeafter diagnosis of type 2 diabetes Prevalence of kidney disease with increasing duration of diabetes Time since diagnosis of type 2 diabetes (years) (n=number alive and examined) Adapted from: Adler AI, Stevens RJ, Manley SE, et al. UKPDS64. Kidney International 2003;63:225-232.

  9. Longer survival of people with diabetes may increase the risk of developing kidney failure • Without specific interventions, 20-40% of people with type 2 diabetes and albuminuria progress to overt kidney disease1 • By 20 years after onset of overt kidney disease ˜20% of people progress to end stage kidney disease1 • The rate of fall in GFR is highly variable between individuals, but not substantially different between type 1 and type 2 diabetes1 • The risk of dying from coronary artery disease is higher in older people with type 2 diabetes than those without; historically this may have affected the number who progress to end stage kidney disease1 • As therapies and interventions for coronary artery disease continue to improve, more people with type 2 diabetes may survive long enough to develop end-stage kidney disease1 Reference: 1. American Diabetes Association. Diabetes Care 2004;27(suppl 1):s79-s83.

  10. Intensive blood glucose control in newly diagnosed patients decreases the risk of developing microvascular complications* *Microvascular complications include retinopathy, nephropathy and neuropathy †Intensive control with sulphonylureas or insulin, versus ‡conventional treatment of diet only Reference: 1. UKPDS Group. UKPDS33. Lancet 1998;352:837-53

  11. Intensive blood glucose and blood pressure control decreases the risk of complications Microvascular endpoints include retinopathy, nephropathy and neuropathy. Surrogate measures of microvascular disease include urinary albumin excretion and retinal photography. • Intensive glucose control (HbA1c 7.0%) vs. conventional glucose control (HbA1c 7.9%) reduces the risk of the following: • Microvascular endpoints 25%1 • Any diabetes-related endpoints 12%1 • Diabetes related death 10%1 • A tight BP control policy 144 / 82 vs. 154 / 87 mmHg reduces risk of: • Stroke 44%2 • Microvascular endpoints 37%2 • Deaths related to diabetes 32%2 • Any diabetes-related endpoints 24%2 References: 1. UKPDS Group UKPDS 33. The Lancet 1998;352;837-853. 2. UKPDS Group UKPDS 38. BMJ 1998;317(7160);703

  12. Diabetes is a burden to healthcare systems • Diabetes is the most common cause of end stage kidney disease1 • Diabetes doubles the risk ofcardiovascular disease (heart attacks,heart failure, angina, strokes)2 • Nearly 1 in 6 people with diabetes arelikely to have clinical depression3 • Intensive management and control ofdiabetes can decrease the burden tohealthcare systems References: 1. State of the Nation, England. Diabetes UK, 2012. http://www.diabetes.org.uk/Documents/Reports/State-of-the-Nation-2012.pdf. Last accessed 17.12.14. 2. Emerging Risk Factors Collaboration (2010). Lancet 375 (9733); 2215–2222 . 3. Ali S et al; Diabet. Med. 23 (11) (2006) 1165–1173.

  13. CKD has a considerable financial impact • The annual cost of chronic kidney disease (CKD) to the NHS in England was estimated at £1.45 billion in 2009-101 • Represents 1.3% of all NHS spending that year1 • Equivalent to £1 in every £77 spent2 • There are believed to be between 0.9 million and 1.8 million people in England who have undiagnosed CKD3 The cost of implementing UK guidelines for a practice of 10,000 patients would be recouped by delaying dialysis for one year in one person4 References: 1. NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014. 2. NHS Choices. 'One million people' with 'undiagnosed' chronic kidney disease. Behind the Headlines. Tuesday August 7 2012. Available at: http://www.nhs.uk/news/2012/08august/ Pages/One-million-people-with-undiagnosed-chronic%20kidney-disease.aspx. Website last accessed on 16.12.14 . 3. Kerr M, Bray B, Medcalf J, et al. Nephrol Dial Transplant 2012;27(Supple 3):iii73-iii80.4. Klebe B, Irving J, Stevens PE, et al. Nephrol Dial Transplant 2007;22: 2504–2512.

  14. Distribution of costs attributable to CKD, 2009–101 • Excess MRSA • £1m *BMD=bone mineral density Reference: 1. Kerr M, Bray B, Medcalf J, et al. Nephrol Dial Transplant 2012;27(Supple 3):iii73-iii80.

  15. Section B – summary • Type 2 diabetes increases the risk of microvascular and cardiovascular complications • Untreated diabetic kidney disease can lead to kidney failure • The risk of kidney disease increases over time since diagnosis • As people live longer, more people with type 2 diabetes will be at risk ofkidney disease • Intensive blood glucose control decreases the risk of microvascular complications • Diabetes and CKD represent a significant financial burden to healthcare systems

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