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Long-standing barriers complicate patient care despite effective DKD treatment options


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3 minutes

The management of diabetes and kidney disease has changed dramatically in recent years. Until the mid-2000s, renin-angiotensin system (RAS) inhibition, glycemic control, blood pressure control, and lifestyle management were the only options. Dipeptidyl peptidase 4 (DPP4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and sodium-glucose co-transporter 2 (SGLT2) inhibitors are game changers. But only if patients can access them.

Maryam Afkarian, MD, PhD
Maryam Afkarian, MD, PhD

“We have no shortage of new tools to manage diabetes and kidney disease,” said Maryam Afkarian, MD, PhD, the Depner Endowed Professor in Nephrology at the University of California, Davis. “Sadly, we are also faced with barriers and challenges to the practical application of these tools.”

Dr. Afkarian will explore some of those barriers in patients with early kidney disease during the symposium Translating Diabetes and Kidney Disease Clinical Trial Findings into Clinical Practice, which will begin at 9:00 a.m. ET Tuesday, June 29. Meg J. Jardine, MD, PhD, Director of the Clinical Trial Center (CTC) and Director of the CTC’s Kidney Health Research at the University of Sydney, Australia, will discuss the care of patients with advanced kidney disease.

Lack of time, lack of coordination between specialists, and lack of early access to specialist care are long-standing challenges for diabetic kidney disease (DKD) treatment, Dr. Afkarian said. So is the continuing growth in diabetes numbers.

In 2018, 13% of the U.S. adults had diabetes—a number that is rising as the general population becomes more obese and sedentary, she said. Diabetes prevalence has increased alongside COVID-19, too. Dr. Afkarian’s patients have gained an average of 10 to 40 pounds during the pandemic, she said.

“That acute jump in obesity and faster march toward diabetes is one more massive burden on a health care system that was barely functioning before the pandemic began,” Dr. Afkarian said.

As the number of people diagnosed with diabetes has continued to rise and diabetes treatment options have expanded, the management of uncomplicated diabetes care has begun to shift from internal medicine to endocrinology, Dr. Afkarian continued. Internal medicine can’t keep up with the flood of new management tools in diabetes, so they have to engage endocrinology much earlier, she added.

“I suspect endocrinology itself is a stressed specialty,” Dr. Afkarian said. “Diabetes is just one of the conditions they deal with. The endocrinology workforce in this country is probably not set up to deal with the current deluge of new people referred for management of diabetes.”

At the same time, the specialists responsible for the treatment of diabetes complications are far less likely to see patients in the early stages when kidney, heart, and other complications are most manageable. For example, nephrologists have the most experience with SGLT2 inhibitors, yet are the least likely to see the patient early enough to be able to use the medications.

Dr. Afkarian is a nephrologist, but patients with diabetes are often referred to her when their glomerular filtration rate is below 30%.  At that point, their kidney disease has progressed to the point they are no longer eligible for the SGLT2 inhibitors that can slow progression of DKD in its earlier stages.

“By the time people with diabetes finally get referred to me, all I can really do is escort them to dialysis, where 20% will die the first year of treatment and about 50% in the first five years,” Dr. Afkarian said. “If we could get to them before they lose so much kidney function, we would have the time to put them on a full complement of protective medications to slow progression of their DKD, keeping the patients off dialysis for years.”


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