Thursday, April 17, 2014

Winning the war against kidney failure

Ed Gregg, the master of diabetes epidemiology, and his team from the CDC, just published their latest report on the state of the nation's epidemic of diabetes. The good news is that the rates of diabetic complications - heart attacks, amputations, kidney failure, fatal hyperglycemic crisis, stroke - have fallen quite a bit since 1990. This is almost certainly do to the widespread application of practice guidelines by specialists and especially primary care providers. Monitoring and managing A1C, blood pressure, lipids and early renal damage is paying off at the national scale.

What about adults without diabetes?
"Trends in the population of adults without diabetes were generally not as promising as those in the population with diabetes, with smaller reductions in the rate of acute myocardial infarction, no significant change in rates of stroke and lower-extremity amputation, and an increase in the rate of end-stage renal disease."
An increase in end-stage renal disease? At the same time that we were making significant inroads against renal failure in diabetes (-28% drop in the rate), we see a swelling of the rates in non-diabetic adults by a whopping 65%. Why is this?

First, early stage chronic kidney disease is often un-noticed by providers who may not understand the implications of apparently small increases in serum creatinine. Second, proteinuria, the hallmark of treatable early renal damage, may not even be sought. Third, blood pressure is hard to reduce, often requiring multiple medications and persistent, frequent monitoring. You can't prevent the progression of early chronic kidney disease with once-a-year visits.

These problems in the quality of care are very much like those that beset diabetes 20 years ago, but we have made great strides by becoming aware of the problem, deciding as a profession that we should and shall do something about it, and marshalling all our resources - guidelines, educators, non-physician providers, reminders, lifestyle changes, new medications - and building them into our ongoing processes of care. In many practices, the optimal care of diabetes is a stated goal and the office uses standing orders, automated reminders and all the tricks of modern systems management to reliably deliver state-of-the-art care for diabetes. It's time to do that for early kidney disease.

Changes in Diabetes-Related Complications in the United States, 1990–2010
Edward W. Gregg, Ph.D., Yanfeng Li, M.D., Jing Wang, M.D., Nilka Rios Burrows, M.P.H., Mohammed K. Ali, M.B., Ch.B., Deborah Rolka, M.S., Desmond E. Williams, M.D., Ph.D., and Linda Geiss, M.A.
N Engl J Med 2014; 370:1514-1523 April 17, 2014 DOI: 10.1056/NEJMoa1310799

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