Nephro- and cardioprotection as an interdisciplinary challenge

Early detection and treatment of renal dysfunction and cardiovascular risk factors in type 2 diabetes mellitus is essential. Experts see a need for action in this area, especially with regard to renal complications. As a solution, they propose multidisciplinary disease management based on the principles of collaborative care and involving actors at different levels.

Currently, around 59 million people in Europe are affected by diabetes. By 2045, this number is expected to increase to 67 million [1]. About 90% of them suffer from type 2 diabetes mellitus (T2DM). If adequate treatment is not provided, these patients are at increased risk for serious health complications such as renal failure and cardiovascular disease, the two leading causes of death in T2DM patients [2,3].

Multidisciplinary integrated care

Nearly one-third of T2DM patients develop cardiovascular disease (CVD) [2] and about 40% develop chronic kidney disease (CKD) [4]. Diabetes is one of the most common causes of end-stage renal failure – in half of the cases it is a diabetic secondary disease [3]. According to current knowledge, renal and cardiac systems influence each other and should not be considered in isolation [5]. Cardiovascular disease is the leading cause of death in adult T2DM patients [2,3]. _HbA1c level has a clear association with cardiovascular events [6]. With poorly controlled blood glucose levels, the risk of myocardial infarction is increased by 67%, the risk of stroke is increased by 51%, and the risk of heart failure increases by 64% [3,5]. However, renal complications also affect mortality risk. Albuminuria and reduced eGFR have been shown to have a significant association with mortality [7].

Regular monitoring and timely treatment of cardiovascular and renal risk factors are central themes of the “A New Era in Diabetes Care” initiative launched in February 2020. Diabetes experts in primary and secondary care from across Europe have joined forces to develop strategies to improve the quality of prevention and treatment [8]. T2DM and sequelae impose a great burden both at the individual level and on the healthcare system. In their report, the experts point out that CVD and CKD are highly correlated, and ignoring warning signs of renal complications significantly increases the likelihood of earlier onset of CVD [9]. Well-controlled renal outcomes in patients with T2DM are also associated with improved quality of life and result in a reduced financial burden on the healthcare system [10,11]. Therefore, one conclusion of the authors of the report is that action is needed to improve the detection and early treatment of renal dysfunction in T2DM. As a solution, they propose an action plan that can be implemented in a multidisciplinary treatment context and is based on the idea of collaborative care. The prerequisite is a therapeutic alliance between the patient and the health professional (e.g. physician, nurse, nutritionist, etc.) based on partnership. The procedure is divided into the three phases “measure”, “treat” and “review” with the aim of preventing CKD or preventing worsening of renal function values.

Barrier management to optimize control of renal complications.

An analysis of the current status shows that there is a need for action on the following points to improve the prevention and treatment of renal dysfunction in T2DM [8]:

Recognize warning signs of chronic kidney disease (CKD)

The 2019 and 2017 IDF guidelines recommend that diabetic patients (types 1 and 2) be screened annually for CKD by assessing estimated eGFR and urinary albumin creatinine ratio (UACR) [12,13]. In reality, however, this is rarely implemented, as a situation analysis conducted in various European countries shows [8,14–16]. One of the reasons is an underestimation of the impact of CKD on CVD-associated mortality risk [16]. Early diagnosis is a key factor in preventing the onset or worsening of renal impairment, so consistent measurement of UACR should be performed in patients with T2DM [17]. In addition, eGFR values should be collected, for example according to the Chronic Kidney Disease Epidemiology Collaboration Equation (CKD-EPI). The expert panel agrees that the performance of these screening tests are a key factor for the control and treatment of renal function values and renal disease. CKD.

Demonstrate advantages of SGLT-2 inhibitors and GLP-1 receptor agonists.

The T2DM treatment paradigm is still strongly focused on glycemic control and the aspect of renal and cardiovascular complications is sometimes neglected. The expert panel attributes the fact that treatment recommendations regarding SGLT-2 inhibitors and GLP1 receptor agonists (GLP-1-RA) are formulated cautiously in certain guidelines, although it has been repeatedly empirically proven that these substance classes have an additional cardiovascular and renal benefit, to the relatively high costs of these modern antidiabetic drugs. They propose to perform a cost-benefit balance to demonstrate that the use of SGLT-2 inhibitors and GLP-1-RA is also economically worthwhile in the long term when savings from delaying renal failure requiring dialysis and hospitalizations due to renal and/or cardiovascular complications are included. Regarding side effects, experts agree that the cardiovascular and renal benefits clearly outweigh any adverse side effects (e.g., urogenital infections), which are usually minor and easily managed. This assessment is also consistent with several recent evaluations of the efficacy and safety of these drug groups [18–20]. Whereby this has to be checked in the individual case and the treatment has to be adjusted if necessary.

Implement quality management measures  

Criteria-driven assessment is needed to continuously improve treatment quality. Actors at different levels should cooperate to this end, both at national and at European and international levels [21]. Particular attention should be paid to the phenomenon of clinical inertia, i.e., a need-based modification of the therapeutic regime [22]. It has been observed that clinical inertia occurs particularly in situations where disease management becomes increasingly complex, such as in patients with T2DM and CKD.
 
Conduct patient education and information campaigns

Therapy adherence is essential for achieving treatment goals. Glycemic control is a key aspect of disease management of diabetes. In patients with T2DM, lifestyle factors and glucose-lowering medications are important measures to achieve glycemic goals [23]. A secondary analysis showed that adherence to oral antidiabetic drugs decreases massively during the treatment period [24]. Promotion of self-management has been shown to help improve glycemic control, positively influencing one of the strongest predictors of diabetes-related complications [25]. To promote compliance, patient education should include targeted information on HbA1c, blood pressure, and other relevant aspects, as well as information on secondary diseases and how to reduce risks.

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HAUSARZT PRAXIS 2020; 15(7): 30-31