Challenges in the Prevention and Management of Diabetic Kidney Diseases

Abstract

If you define the problem correctly, you almost have the solution" Steve Jobs BACKGROUND Diabetic kidney disease (DKD) is one of the common complications of diabetes mellitus, which substantially decreases the quality of life and increases the risk of premature mortality (1). Although it is the most common cause of end-stage renal disease (ESRD) (2), the mortality is mostly due to cardiovascular diseases and therefore DKD is regarded as a major cardiovascular risk factor (3, 4). Due to its chronic and slowly progressing nature, DKD is generally diagnosed by screening tests showing albuminuria or low eGFR, or both in subjects with diabetes. Up to one-third of patients with type 1 diabetes (T1DM) (5-7)and nearly half of patients with type 2 diabetes (T2DM) have DKD (6,(8)(9)(10)). Yet, fewer of them receive optimal care to prevent DKD progression and avoid the cardiovascular and renal endpoints (11).Although the term "Diabetic Nephropathy" is used interchangeably with DKD, the former more specifically describes the histological alterations such as glomerular basement membrane thickening, or mesangial proliferation observed in subjects with T1DM, which predominantly occurs due to chronic hyperglycemia (12). However, DKD observed in subjects with T2DM involves Diabetic Nephropathy but also the alterations seen due to other causes such as aging, hypertension, or obesity. This is probably the reason for observing DKD more frequently in subjects with T2DM. As multiple risk factors play role in the pathogenesis of DKD and its cardiovascular consequences, intensive glucose control is not enough to prevent renal and cardiovascular endpoints in DKD (13). Therefore, chronic risk management is essential along with good glycemic regulation, to prevent the occurrence and progression of DKD and to reduce the premature cardiovascular events in patients with diabetes (14-17).Unfortunately, the global data shows that people with diabetes are not under good glycemic control, nor they attain the metabolic targets (18)(19)(20). We have recently performed a nationwide survey in Turkey (6). Our findings replicate the global data and show that less than half of patients with T2DM reach the target HBA1c levels and only 10% of them simultaneously attain the targets for blood glucose, blood pressure, LDL Cholesterol. The situation is even worse in patients with T1DM, with less than 5% attainment rates of the three targets. When we also consider smoking cessation and regular exercise, only 1.5% of patients with both types of diabetes reach all these targets simultaneously (6). There is also significant inertia in establishing appropriate targets and

Efficacy of astragalus combined with renin-angiotensin-aldosterone system blockers in the treatment of stage III diabetic nephropathy: a systematic review and meta-analysis

“…Randomization was mentioned in all 32 reports. However, only 13 trials indicated that the random grouping method applied was the random number table [ 18 , 22–24 , 32–35 , 37 , 38 , 40 , 46 , 49 ]. Nine trials did not mention the use of allocation concealment [ 21 , 29–31 , 33 , 38 , 41 , 45 , 49 ].…”

“…Twenty-two trials reported Scr, comprising 1685 patients (852 patients in the combination treatment group and 832 patients in the control group) [ 18 , 19 , 21–23 , 25 , 27–29 , 31 , 32 , 34 , 36 , 38 , 40–44 , 51 ]. The meta-analysis results showed low heterogeneity among the studies; hence, the fixed effect model was used for data analysis.…”

“…BUN was reported in sixteen eligible studies, including 1238 patients (624 in the treatment group and 614 in the control group) [ 19 , 21–23 , 25 , 27–29 , 33 , 34 , 38 , 40 , 42 , 46 , 48 , 49 ]. Due to the low heterogeneity of the test results, the fixed effects model was used for data analysis (I 2 = 36%; p = 0.07).…”

“…Twelve studies reported HbAlc and included 879 patients (442 in the treatment group and 437 in the control group [ 23 , 25 , 30 , 31 , 33 , 34 , 36 , 37 , 40 , 41 , 45 , 46 ]. A fixed effects model was employed due to the low heterogeneity (I 2 = 12%; p = 0.33).…”