What’s the

on the kidneys?

Type 2 diabetes is the leading cause of chronic kidney disease (CKD), representing nearly 40%1 of its cases. While Type 2 diabetes is associated with substantially increased risk of all-cause and cardiovascular mortality in the US population, this excess risk is concentrated in the subgroup of people with diabetes and kidney disease.2

By 2060, the number of US adults with diagnosed diabetes is projected to nearly triple compared to 2014, which will have obvious repercussions on the increase in diabetic kidney disease.

How does diabetes cause damage to the kidneys?

Diabetes results in the following factors that cause damage to the kidneys over time:

  • Hyperglycemia
  • Hypertension
  • Activation of the renin angiotensin system
  • Inflammation
  • Oxidative stress

ahajournals.org. Accessed 03.2024.

e-dmj.org. Accessed 03.2024.

How is a type 2 diabetes patient diagnosed with kidney damage?

Since CKD is largely asymptomatic in its early stages, the only way to know how well a patient’s kidneys are/are not working is to conduct chronic kidney disease testing through two screening measures, eGFR and UACR. Both metrics are needed to diagnose whether kidney disease is present and at what stage.

Test 1: eGFR (a diagnostic test)

Most doctors automatically check a patient’s eGFR or estimated Glomerular Filtration Rate as part of normal blood work. The eGFR blood test will indicate how well the kidneys are functioning by measuring the kidneys’ ability to filter toxins or waste from the blood. The eGFR test can accurately measure how much blood these filters clean every minute based on a patient’s body size. If the blood is not being filtered properly, kidney disease is present and dangerous toxins will build up in the body.

Test 2: UACR (another diagnostic test)

Even if a patient’s eGFR is considered normal (more than 60), he/she could still have chronic kidney disease due to diabetes. The American Diabetes Association, Kidney Disease Improving Global Outcomes and American Academy of Family Practitioners Guidelines recommend also checking a patient’s UACR or Urine Albumin-to-Creatinine Ratio at least annually. This UACR urine test will check for level of protein in the urine as a sign of kidney damage and can help determine the stage of chronic kidney disease. The UACR value is important to understand the staging of CKD even for those with eGFR< 60 (abnormal kidney function).

Diagnosis and determination of the severity of chronic kidney disease and function relies on the results of these routine measures (if reduced eGFR <60 mL/min/1.73 m2 for 3 or more months and/or persistently elevated UACR ratio ≥30 mg/g.)*

* kidney.org/kidneydisease. Accessed 03.2024.

If a patient has type 2 diabetes and is also diagnosed with kidney disease, what are the next steps?

Ideally, the patient’s clinical team will create a custom treatment plan, including therapeutics, diet, other lifestyle behavior changes, and how often the patient should be seen and by whom.

Controlling blood sugar and pressure.

Type 2 diabetes patients must be educated on the best ways to keep their blood sugar levels controlled. Typically, the clinical team outlines a therapeutic (i.e., hypoglycemic), diet and exercise plan. High blood pressure can also increase a patient’s chances for progressing to kidney failure.

Adding new therapies and subtracting others.

ACE inhibitors and ARBs are first line treatments for all patients with type 2 diabetes and CKD. For years, these were the only medications that specifically altered cardiorenal risk.

New advancements, over the past several years, have changed the treatment landscape. Consensus guidelines now also recommend the addition of SGLT2i, GLP1 receptor agonists, and non-steroidal mineralocorticoid antagonists on top of ACEi/ARBs, based upon robust evidence of reduction in kidney progression, cardiovascular events, and all-cause mortality.

Given the costs, potential side-effects, and compliance issues with a multiple drug regimen that may continue for life, a risk-based approach to applying all new drugs, and elimination of drugs that may adversely affect kidney function (e.g., NSAIDs), may be advantageous.

Educating the patient about the importance of diet, as it relates to their disease.

Type 2 diabetes patients with chronic kidney disease need to find the right balance of protein consumption as it directly relates to progression of kidney disease. Plus, they’ll need to be more mindful about the level of salt in their diet to better control their high blood pressure. A dietician referral may be appropriate to help them better manage what and how much they eat.

mayoclinic.org/diseases-conditions/diabetes. Accessed 03.2024.

ncbi.nlm.nih.gov. Accessed 03.2024.

How does a clinician know how serious a patient’s CKD diagnosis may be?

As soon as a patient with type 2 diabetes is diagnosed with chronic kidney disease, his/her risk for disease progression (significant loss in kidney function and progression toward kidney failure and the need for dialysis or a transplant) should be assessed. The kidneyintelX.dkd test, a simple blood test that can be ordered with traditional blood work, does not require fasting, and has been recognized as the first and only FDA authorized prognostic test to identify those adult patients with type 2 diabetes and chronic kidney disease (stages 1-3b) who are at increased risk.

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Why is an early diagnosis of diabetic kidney disease so important?

Early diagnosis of chronic kidney disease in patients with type 2 diabetes is critical, as it may allow for more immediate clinical care that mitigates progression of the disease.

Further, an early diagnosis can also mitigate the risk for heart disease events and mortality, the leading consequences of poor cardiovascular-kidney-metabolic health, as outlined in the November 2023, AHA Presidential Advisory.

The NIH NIDDK USRDS data from 2020 also highlights the prevalence of CVD in patients with CKD, as noted in the chart below. The burden of CVD increases significantly with advancing stages of CKD.

What is the general impact that type 2 diabetes has on other organs in the body?

The relationship between diabetes, chronic kidney disease (CKD), and heart disease is an example of the ways our organs are connected.

The risk factors for each condition are similar and include high blood sugar, high blood pressure, family history, obesity, unhealthy diet, and physical inactivity.

Diabetes, or high blood sugar, can slowly damage the kidneys, and, over time, they can stop filtering blood well, leading to chronic kidney disease.

When the kidneys don’t work well, more stress is put on the heart and vasculature. The heart needs to pump harder to get blood to the kidneys. Metabolic and hemodynamic factors in CKD leads to hypertension, endothelial dysfunction, and atherosclerotic and calcific vascular disease. This can lead to heart failure, heart attacks, and strokes, which combined are the leading causes of death in the United States.

What is the impact on mortality when a patient has both diabetes and CKD?

In a nationwide sample, although diabetes and CKD were each separately associated with high 10-year mortality rates (7.7% and 11.5%, respectively), the combination of diabetes and CKD was linked to a synergistically higher 10-year mortality rate (31.1%).1

Compared with middle-aged individuals who have normal or mildly decreased kidney function (estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m2), those with stage 4 CKD (15–29 mL/min/1.73 m2) have > 20-year-shorter life expectancy, with death resulting from CVD being a major competing risk for the development of kidney failure requiring kidney replacement therapies.2

1 Afkarian M, Sachs MC, Kestenbaum B, et al. Kidney disease and increased mortality risk in type 2 diabetes. J Am Soc Nephrol. 2013;24(2):302-308. doi:10.1681/ASN.2012070718.

2 Turin TC, Tonelli M, Manns BJ, Ravani P, Ahmed SB, Hemmelgarn BR. Chronic kidney disease and life expectancy. Nephrol Dial Transplant. 2012;27:3182–3186. doi: 10.1093/ndt/gfs052

What is the impact of diabetes and CKD on cardiovascular events?

The November 2023, AHA Presidential Advisory introduces the Cardiovascular-kidney-metabolic (CKM) syndrome, defined as a health disorder attributable to connections among obesity, diabetes, chronic kidney disease (CKD), and cardiovascular disease (CVD), including heart failure, atrial fibrillation, coronary heart disease, stroke, and peripheral artery disease. CKM syndrome includes those at risk for cardiovascular disease and those with existing CVD disease.