GUEST EDITORIAL

Abstract

Diabetes mellitus and kidney disease are two of the most feared long-term conditions with their impact affecting all ages and potentially diminishing quality of life, both in the short and long term. Either one on its own is a major factor in any persons’ life, so one can imagine the impact for the individual, family members and carers when someone develops diabetic kidney disease. This is so not only for the individual but also for the health system where diabetes has long been the single most common cause of end-stage renal failure in the world. The impact of diabetic kidney disease is felt in all populations, and in some parts of the world, the dual assault of diabetes and kidney disease reaches ‘epidemic proportions’. In addition, the person with diabetic kidney disease is at very high risk of all other diabetic microvascular and macrovascular complications making the need for integrated and comprehensive care even more crucial as many different healthcare professionals and specialities will be involved in the care. The breadth of the papers in this issue highlight the complexities involved for someone with diabetic kidney disease and the need for the diabetes, kidney and primary care tribes to work closely together. Care for those with diabetic kidney disease has progressed in the United Kingdom over several years, however, we are still missing opportunities to improve outcomes and much more can and should be done. Meaningful integrated care with the patient at the centre is an absolute priority. Much of the kidney disease in type 1 diabetes affects those who develop the disease in childhood and who have to manage the complexities of diabetes through puberty and adolescence with all the challenges that brings and again there is a parallel in kidney care where transition from paediatric to adult practice is associated with up to 30–40% unnecessary kidney transplant loss. Our services in general are unfriendly to young people between the ages of 14 and 25 years. There is an urgent need for the UK health system and the practitioners within it, to find better ways to support individuals and their families at this time. As obesity increases in young people, not only is the prevalence of type 2 diabetes increasing but also its age of onset is falling, especially in those from ethnic minorities. Over the last few years, some centres have seen a frightening increase in the number of young people with type 2 diabetes. This can only increase the risk of future diabetes complications, including kidney disease. Different ethnicities are affected to different degrees in diabetic kidney disease with the prevalence of type 2 diabetes risk and kidney disease risk being higher in those of African or Caribbean origin and also in those of Asian origin however, all ethnicities can be affected. Overall, therefore, as the number of young people with diabetes increases, particularly in those from ethnic minorities, we face the possibility of a devastating increase the prevalence of diabetic kidney disease and other complications. Advances in the treatment of diabetes with more intensive insulin regimens and greater focus on good glycaemic control and in the early detection of kidney disease with the description, in the 1980s, of the utility of microalbuminuria as a predictor for progressive kidney damage have contributed greatly to the prevention of advanced diabetic kidney disease. Equally, the increasing knowledge of the importance of tight blood pressure control, the advent of renin–angiotensin system inhibitors and other therapeutic advances have all reduced the risk of an individual with diabetes developing diabetic kidney disease and of the kidney disease progressing if it should be detected at an early stage. Indeed, for most individuals, advanced kidney disease takes 10–20 years after the onset of diabetes to develop, therefore, it should be very amenable to preventative strategies and indeed, the incidence in cohorts of newly diagnosed diabetes has fallen. Late detection in type 2 diabetes, with an estimated 850,000 with the disease who are undiagnosed in the United Kingdom, and a failure to grasp the opportunities of modern diabetes management, however, mean many do not gain the benefits of this progress. On a population level, as the prevalence of diabetes increases the numbers afflicted by diabetic kidney disease have grown alarmingly. Unfortunately not all individuals benefit from the advances in diabetes and kidney disease detection and management. A greater focus is required on engaging patients in their own care with more support, education and information, early detection of both diabetes and kidney disease and increasing health care determination to offer intensive interventions especially to those at higher risk. We need particular strategies for those who are different or difficult to reach. New treatments will also be welcome as some individuals fail to respond to current strategies and new therapeutic approaches will be required for these. For many, however, early and appropriate application and uptake of current knowledge and treatments will be highly effective in preventing this potentially devastating complication. For those who have developed advanced kidney disease, there has also been much progress made over the last 20 years. Twenty years ago many individuals of all ages with diabetic kidney disease did not routinely get offered renal replacement therapy or transplantation. Now not only is dialysis and renal transplantation standard options for those with diabetes but for those with type 1 diabetes pancreas and kidney transplantation or maybe, in the future, increasingly islet and kidney transplantation. However, one must not underestimate the morbidity and mortality associated with diabetes and renal replacement therapy. This supplement is a timely overview with well-written comprehensive papers and will, we hope, contribute to a greater awareness of the complexities of care that individuals unfortunate enough to develop this long-term condition must contend. The guest editors have no potential conflicts to declare. Donal has been a Consultant Renal Physician at Salford Royal NHS Foundation Trust since 1992. He was appointed the first National Director for Kidney Care in England in 2007. After gaining degrees in Physiology and Medicine from Manchester University, Donal trained in Renal and Internal Medicine in Leicester, Nottingham, Manchester and Edinburgh. Research training was as a Medical Research Council fellow at Hopital Necker in Paris. Donal has published more than 80 peer review papers, book chapters and articles across the spectrum of nephrology, dialysis and transplantation. Donal was the inaugural president of the multi-professional British Renal Society and is a former Treasurer and President elect of the Renal Association. Donal chaired the National Service Framework for renal services and leads the policy team and implementation strategy for kidney services in England. This has included aligning kidney policy with public health and vascular risk reduction programmes, early detection schemes, integrated care and development of a chronic disease management model of care for advanced kidney disease. Current research interests include epidemiology of chronic kidney disease and acute kidney injury, the biology and management of progressive kidney disease and models of service delivery to optimise outcomes in advanced kidney disease including support during adolescence and transplantation. Stephen Thomas is Consultant in Diabetes and Endocrinology at Guy's & St Thomas’ part of the King's Healthcare partners Academic Health Sciences Centre. He is active in a broad range of diabetes clinics including diabetes kidney clinics. He has both hospital and community diabetes responsibilities. His main research interest is in diabetic complications particularly kidney disease. He teaches on a number of local and national diabetes courses and contributes as an abstract marker for the Diabetes UK Annual Professional Conference. He has been on the NCCDG advising NICE on the treatment of anaemia in chronic kidney disease representing the Royal College of Physicians.