Screening For Diabetic Kidney Disease Research Articles

Diabetic kidney disease in type 2 diabetes: a consensus statement from the Swiss Societies of Diabetes and Nephrology

Diabetic kidney disease is highly prevalent in patients with type 2 diabetes and is a major cause of end-stage renal disease in Switzerland. Patients with diabetic kidney disease are among the most complex patients in diabetes care. They require a multifactorial and multidisciplinary approach with the goal to slow the decline in glomerular filtration rate (GFR) and cardiovascular morbidity. With this consensus we propose an evidence-based guidance to health care providers involved in the care of type 2 diabetic patients with diabetic kidney disease.First, there is a need to increase physician awareness and improve screening for diabetic kidney disease as early intervention may improve clinical outcomes and the financial burden. Evaluation of estimated GFR (eGFR) and spot urine albumin/creatinine ratio is recommended at least annually. Once it is diagnosed, glucose control and optimisation of blood pressure control with renin-angiotensin system blockers have been recommended as mainstay management of diabetic kidney disease for more than 20 years. Recent, high quality randomised controlled trials have shown that sodium-glucose cotransporter-2 (SGLT2) inhibition slows eGFR decline and cardiovascular events beyond glucose control. Likewise, mineralocorticoid receptor antagonism with finerenone has cardiorenal protective effects in diabetic kidney disease. Glucagon-like peptide-1 (GLP1) receptor agonists improve weight loss if needed, and decrease albuminuria and cardiovascular morbidity. Lipid control is also important to decrease cardiovascular events. All these therapies are included in the treatment algorithms proposed in this consensus. With advancing kidney failure, other challenges may rise, such as hyperkalaemia, anaemia and metabolic acidosis, as well as chronic kidney disease-mineral and bone disorder. These different topics and treatment strategies are discussed in this consensus. Finally, an update on diabetes management in renal replacement therapy such as haemodialysis, peritoneal dialysis and renal transplantation is provided. With the recent developments of efficient therapies for diabetic kidney disease, it has become evident that a consensus document is necessary. We are optimistic that it will significantly contribute to a high-quality care for patients with diabetic kidney disease in Switzerland in the future.

Association Between Serum Albumin Level and Microvascular Complications of Type 2 Diabetes Mellitus.

ObjectiveTo analyze the associations between serum albumin (sALB) level and diabetic microvascular complications, including diabetic retinopathy (DR) and diabetic kidney disease (DKD), in patients with type 2 diabetes mellitus (T2DM).MethodsThis retrospective study included 951 hospitalized patients with T2DM who had completed screening for DR and DKD during hospitalization. Patients were divided into three groups according to sALB tertiles. Multivariate logistic regression analysis was used to assess the association of sALB with microvascular complications.ResultsThe prevalence of DR, DKD and macroalbuminuria increased with decreasing sALB levels. Multivariate logistic regression analysis showed that lower levels of sALB (Q1) were associated with higher risk of DR (odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.12–2.26), DKD (OR: 3.00, 95% CI: 2.04–4.41) and macroalbuminuria (OR: 9.76, 95% CI: 4.62–20.63) compared with higher levels of sALB (Q3) after adjustment for other risk factors. After stratification by sex and age, the effect of lower levels of sALB (Q1) on DR incidence was more obvious in patients with male (OR: 1.60, 95% CI: 1.00–2.56), and aged<65 years (OR: 1.74, 95% CI: 1.14–2.65) (P < 0.05 for all); the effect of lower levels of sALB (Q1) on the incidence of DKD was significant in both males (OR: 3.78, 95% CI: 2.26–6.32) and females (OR: 2.35, 95% CI: 1.26–4.35) (P < 0.05 for all), while only the age <65 years (OR: 3.46, 95% CI: 2.16–5.53) was significant in the age subgroup (P < 0.001).ConclusionDecreased sALB levels may be an independent risk indicator of DR and DKD in patients with T2DM, and significantly associated with DKD progression. For DR screening, special attention should be paid to men aged <65 years, while screening for DKD should pay attention to people <65 years old.

Biomarkers for early diagnosis of diabetic kidney disease: still a long way to go.

Biomarkers for early diagnosis of diabetic kidney disease: still a long way to go.

ASIAN PACIFIC SOCIETY OF NEPHROLOGY CLINICAL PRACTICE GUIDELINE ON DIABETIC KIDNEY DISEASE - EXECUTIVE SUMMARY.

Introduction: COVID-19 is now a global pandemic affecting millions of people Patients on dialysis are at an increased risk to COVID-19 infection due to their exposure in the health care setting Strategies for infection control and prevention are also being implemented in the dialysis units because of the increased risk of virus transmission within the unit Objective: Describe the different measures and strategies done to mitigate the spread of COVID-19 outbreak in a hospital based dialysis centre Methods: Review of the epidemic course with contact tracing was done from March 14 to May 14, 2020 in the dialysis unit of a tertiary hospital Results: Of 167 haemodialysis patients, 20 were considered COVID-19 suspects Eight tested positive-2 were traced to be exposed with the first confirmed case, 2 were handled by a COVID-19 infected healthcare worker (HCW) who was asymptomatic at time of contact while 2 asymptomatic patients tested positive during mass screening Two of 67 HCWs tested positive were exposed to patients Key interventions during the course of the outbreak included: mass testing of patients and HCWs after identifying 6 patients and 2 HCWs infected with COVID-19 using nasopharyngeal/oropharyngeal swabs by RT-PCR;dialysis of COVID-19 confirmed and suspected cases in isolation rooms separate from the dialysis unit (instead of cohorting);provision of adequate protective personal equipment for HCWs and surgical masks for all patients, environmental disinfection especially in the waiting area with strict social distancing and screening for signs and symptoms at the entrance of the unit Conclusion: Infection control strategies are needed to manage the spread of COVID-19 in dialysis centres These infection prevention measures should be implemented at the first indication of transmission in the area and should be maintained for the duration of the pandemic and until the area show no more reports of transmission

ASIAN PACIFIC SOCIETY OF NEPHROLOGY CLINICAL PRACTICE GUIDELINE ON DIABETIC KIDNEY DISEASE.

ASIAN PACIFIC SOCIETY OF NEPHROLOGY CLINICAL PRACTICE GUIDELINE ON DIABETIC KIDNEY DISEASE.

Screening for diabetic kidney disease in primary care: A quality improvement initiative.

Gaps in care currently exist between diabetic kidney disease (DKD) guidelines and diabetes management in primary care settings. Implementation of quality improvement (QI) initiatives often improves these gaps in care. This article outlines a QI initiative exploring whether a local Federally Qualified Health Center could improve rates of screening for microalbuminuria, diagnosis of DKD, and treatment of the disorder in patients with type 2 diabetes mellitus.

Urinary orosomucoid 1 protein to creatinine ratio as a potential biomarker for early screening of kidney impairment in type‐2 diabetes patients

Early screening of diabetic kidney disease (DKD) remains a major challenge. Our aim was to evaluate the value of urinary orosomucoid 1 protein (UORM1) in early renal impairment screening in type-2 diabetes patients. The concentration of UORM1, the UORM1-to-creatinine ratio (UORM1CR), the urinary albumin-to-creatinine ratio (ACR), the alpha-1-microglobulin-to-creatinine ratio (A1MCR) and estimated glomerular filtration rate (eGFR) were measured in 406 type-2 diabetes patients. Any positive values for ACR, A1MCR and/or eGFR were considered as indicative of renal impairment. On average, the levels of UORM1 and UORM1CR were about seven times higher in subjects with renal injury than in those without. Both UORM1 and UORM1CR, when adjusted via logarithm-transformation, were significantly related to ACR, A1MCR and eGFR levels. The highest correlation was observed between UORM1CR and A1MCR (r = 0.85, P < .001). The cut-off values for UORM1 (2.53 mg/L) and UORM1CR (3.69 mg/g) for the early diagnosis of kidney impairment were obtained from receiver operating characteristic curves. UORM1CR obviously had higher diagnostic efficiency corresponding to 83.26% sensitivity and 90.32% specificity than UORM1. Likewise, its sensitivity was higher than those of ACR, A1MCR and eGFR. Bad glycaemic control had the highest risk of increased UORM1CR (odds ratio [OR] = 2.81, P < .001), while high HDL-C (high-density lipoprotein cholesterol) decreased the risk of increased UORM1CR (OR = 0.38, P = .017). The UORM1CR (>3.69 mg/g) has the high diagnostic efficiency for the early screening of renal impairment in type-2 diabetes patients. Furthermore, good glycaemic control and high HDL-C might be protective factors against UORM1CR increase.

Changes in diabetes distress among people with type 2 diabetes during a risk screening programme for diabetic kidney disease – Longitudinal observations of the PRIORITY study

AimsTo investigate levels and changes in diabetes distress over the course of the PRIORITY (Proteomic prediction and Renin angiotensin aldosterone system Inhibition prevention Of early diabetic nephRopathy In people with TYpe 2 diabetes and normoalbuminuria) randomised controlled trial of screening for diabetic kidney disease (DKD) risk among people with type 2 diabetes (T2D) at a specialist diabetes clinic in Denmark. MethodsOf 436 trial participants with T2D, 216 were invited to complete the 17-item diabetes distress scale at the time of screening (T1, n = 180), immediately after receiving the screening results at 6–8 weeks (T2, n = 169), and at 12 months follow up (T3, n = 107). Linear mixed models were used to explore changes in diabetes distress. ResultsNo significant changes in diabetes distress were observed between the time of screening, receiving results, and at 12 months. Changes in diabetes distress were not influenced by diabetes empowerment, sense of coherence, or perceived support for diabetes self-management. ConclusionsIn contrast to previous studies demonstrating that screening programmes can have negative psychological consequences, our findings indicate that participating in this screening programme for DKD does not influence emotional burden or physician-related distress among people with T2D.

Urinary N-acetyl-beta-d-glucosaminidase (NAG) with neutrophil gelatinase-associated lipocalin (NGAL) improves the diagnostic value for proximal tubule damage in diabetic kidney disease.

Screening for diabetic kidney disease (DKD) remains a challenge; however, there has been an ongoing research to investigate the diagnostic value of different biomarkers to identify DKD. The aim of this study was to assess the diagnostic value of both N-acetyl-beta-d-glucosaminidase (NAG) and neutrophil gelatinase-associated lipocalin (NGAL) in the progression of DKD. This cross-sectional case-control study included 92 type 2 diabetic patients with or without DKD. Urinary NAG and NGAL were measured to evaluate their diagnostic values as biochemical markers related to DKD. Both urinary NAG and NGAL levels were significantly higher among patients with DKD. In multiple linear regression analysis, NAG showed a positive significant association with NGAL in the three different adjusted models, while no significant correlation with fasting blood glucose, glycated hemoglobin, serum creatinine, estimated glomerular filtration rate, and albumin creatinine ratio were observed. The area under the curve for NGAL was 0.659 (p = 0.01) and 0.564 (p = 0.297) for NAG in DKD patients. This study demonstrates the association between urinary NAG and NGAL as a tubular damage marker for DKD although longitudinal studies are needed to evaluate its diagnostic value.

How Does Risk Screening for Kidney Disease Influence Diabetes Distress?

Background: Screening for future risk of diabetic kidney disease (DKD) in people with type 2 diabetes (T2D) and normal kidney function was conducted in the clinical multicenter intervention trial PRIORITY (Proteomic prediction and Renin angiotensin aldosterone system Inhibition prevention Of early diabetic nephRopathy In TYpe 2 diabetic patients with normoalbuminuria). Risk screening was based on a urinary proteomic analysis categorizing the patients at high or low risk for DKD. Little is known about how risk-assessments affect patients. However, screening for DKD is likely to increase diabetes distress (DD), as DD is linked to specific diabetes stressors such as worrying about complications. Aim: To investigate to what extent DD was affected by screening and individualized information about future risk of DKD. Methods: Of 436 participants in the Danish part of PRIORITY, 217 were asked to complete a full diabetes distress scale (DDS) and 139 completed DDS at screening visit (T1) and after provision of screening results (T2, 6 weeks after T1). DDS was repeated in 84 at a follow-up visit (T3, 12 months after T2). DD differences were explored with wilcoxon signed-rank test and subgroup differences with paired t-test. Results: Participants’ mean age was 61 years, 37 % women, mean diabetes duration 10 years, mean HbA1c 54mmol/mol, 4 % had high overall DD and 12 % were categorized as having high risk of DKD. No significant changes were found in DD between T1, T2 and T3. Mean DD differences [SD] between T1 to T2 was 0.02 [0.38], p=0.65 and between T2 and T3 0.01 [0.35], p=0.88. No significant differences in DD changes were found when comparing participants with high vs. low initial DD or when comparing participants in high vs. low risk of DKD. However, few participants had high DD at T1 and few had high risk of DKD. Conclusions: The study indicated that screening for future risk of DKD does not increase DD in people with T2D. Future studies should explore potential subgroup differences further as well as the mechanisms behind the results. Disclosure L.E. Joensen: None. K.P. Madsen: None. M. Frimodt-Moller: None. N. Tofte: None. I. Willaing: None. M. Lindhardt: None. P. Rossing: Advisory Panel; Self; Novo Nordisk A/S, AstraZeneca, Boehringer Ingelheim GmbH. Research Support; Self; AstraZeneca, Novo Nordisk A/S. Advisory Panel; Self; Astellas Pharma US, Inc.. Stock/Shareholder; Self; Novo Nordisk A/S. Advisory Panel; Self; Bayer AG.

Prognosis and treatment of diabetic nephropathy: Recent advances and perspectives

Approximately 20 to 40% of patients with type 1 or type 2 diabetes develop diabetic kidney disease. It is a clinical syndrome characterized by persistent albuminuria (>300mg/24h, or 300mg/g creatinine), a relentless decline in glomerular filtration rate, raised arterial blood pressure and enhanced cardiovascular morbidity and mortality. The natural course of classical diabetic nephropathy is initially microalbuminuria or moderately increased urine albumin excretion (30–300mg/g creatinine). Untreated microalbuminuria may then rise gradually, reaching severely increased albuminuric (macroalbuminuria) over 5 to 15 years. Glomerular filtration rate then begins to decline and end-stage renal failure is reached without treatment in 5 to 7 years. Regular, systematic screening for diabetic kidney disease is needed to identify patients at risk for, or with presymptomatic stages of diabetic kidney disease. Multifactorial intervention targeting glucose, lipids and blood pressure including blockade of renin angiotensin system and lifestyle, has improved renal and cardiovascular prognosis and reduced mortality with 50%. Recent data suggest beneficial pleiotropic effects on renal endpoint with new glucose lowering agents. It is also being investigated if blocking aldosterone could be an option as a potential new treatment. Thus, although diabetic nephropathy remains a major burden, prognosis has improved and new options for further improvements are currently tested in phase 3 clinical renal outcome studies.

Study of Renal Profile In Diabetic Patient at Nobel Medical College Teaching Hospital, Biratnagar

Background Diabetes Mellitus (DM) is one of the most common health problem characterizd by hyperglycemia. Type II Diabetes Mellitus is the most common one. Diabetic nephropathy is the most common clinical condition arises with in these patients which progressively leads to impairment in kidney’s function. Measurement of microalbumin in urine is the earliest dectactable stage of diabetic kidney disease.Material and Methods The total of 200 diabetic patients (112 males and 88 females) were enrolled and biochemical estimations including blood glucose level, serum creatinine, blood urea, urine albumin was conducted.Results Prevalance of microalbuminuria was 26 % in type II diabetic patients.Renal functions parameters like blood urea and serum ceratinine were higher in patients with positive microalbuminuria.60 % of diabetic patients are normoalbuminrics and rests 14% are proteinurics.Conclusion Various factors like increasing age, duration of diabetics, blood sugar level,blood urea, serum creatinine are the causes for microalbuminuria and proteinuria. Therefore, to rule out the early screening of diabetic kidney disease, DM patients should get routinely checked up with blood sugar level as well as renal profile test like serum creatinine, blood urea and albumin level in urine.Journal of Nobel Medical College Vol.5(2) 2016; 1-4

Screening for diabetic kidney disease in primary care for the underinsured: A quality improvement initiative

PurposeScreening rates for DKD in primary care are low, even though diabetes accounts for 44% of all new kidney disease cases. The purpose of this project was to determine if a primary care team for the underinsured improved screening and diagnosis of diabetic kidney disease (DKD) after initiating a quality improvement (QI) process. MethodsA chart audit with feedback, provider education of clinical practice guidelines, and strategies from TeamSTEPPS™ were implemented with the inter-professional primary care team. ResultsPre/post-intervention chart audit analysis showed the frequency of ordering microalbumin increased from 50.3% (n=148) to 75% (n=148), and diagnosing DKD rose from 3.3% (n=10) to 10.7% (n=21) over three months (P=.000). ConclusionImplementing a QI process in underinsured primary care centers improved the compliance of proper screening and diagnosing DKD AND introduced inter-professional practice competencies and teamwork strategies not previously recognized at the centers.

The Clinical Utility of SUDOSCAN in Chronic Kidney Disease in Chinese Patients with Type 2 Diabetes.

There are gaps between recommendations on regular screening for diabetic kidney disease (DKD) and clinical practice especially in busy and low resource settings. SUDOSCAN (Impeto Medical, Paris, France) is a non-invasive technology for assessing sudomotor function using reverse iontophoresis and chronoamperometry which detects abnormal sweat gland function. Vasculopathy and neuropathy share common risk factors and we hypothesized that SUDOSCAN may be used to detect chronic kidney disease (CKD). Between 2012 and 2013, SUDOSCAN was performed in a consecutive cohort of 2833 Hong Kong Chinese adults with type 2 diabetes. Chronic kidney disease was defined as estimated glomerular filtration rate <60 ml/min/1.73m2. In this cross-sectional cohort (mean age 58.6±9.5 years, 55.7% male, median disease duration 8 [interquartile range 3–14] years), 5.8% had CKD. At a cut-off SUDOSCAN-DKD score of 53, the test had sensitivity of 76.7%, specificity of 63.4% and positive likelihood ratio of 2.1 to detect CKD. The area under receiver operating characteristic curve for CKD was 0.75 (95% confidence interval 0.72–0.79). Patients without CKD but low score had worse risk factors and complications than those with high score. We conclude that SUDOSCAN may be used to detect patients at risk of impaired renal function as part of a screening program in Chinese population, especially in outreach or low resource settings.

Glomerular structure in IDDM women with low glomerular filtration rate and normal urinary albumin excretion.

Eight women with insulin-dependent diabetes mellitus (IDDM) with low creatinine clearance rate (CCR) and normal urinary albumin excretion (UAE) were compared with three other groups of diabetic women: 19 with normal creatinine clearance rate (CCR) and UAE, 7 with normal CCR and microalbuminuria, and 7 with low CCR and microalbuminuria. The four groups were similar in age, duration of diabetes, HbA1, incidence of urinary tract infection, prevalence of bladder neuropathy, and urinary urea nitrogen excretion rate. The prevalence of hypertension was similar among the groups, although mean arterial pressure was higher in the low CCR and microalbuminuria group. Renal area index was lower in the low CCR and normal UAE groups than in the other groups of diabetic patients, but was not different from normal. Morphometric measures of mesangial expansion and estimates of arteriolar hyalinosis and global glomerulosclerosis were increased to a similar degree in the low CCR and normal UAE, normal CCR and microalbuminuria, and low CCR and microalbuminuria groups compared with the group without abnormalities of renal function. Therefore, it is likely that diabetic glomerulopathy is, at least in part, responsible for the loss of glomerular filtration rate seen in the low CCR and normal UAE patients. Thus, the definition of incipient nephropathy may have to be expanded beyond the concept of microalbuminuria if longitudinal study of such patients reveals an increased risk of the subsequent development of overt nephropathy. Finally, screening for diabetic kidney disease among IDDM patients should include determination of glomerular filtration rate and measurement of UAE and blood pressure, especially among women.