MORE than one-third of Australians with type 2 diabetes will subsequently develop chronic kidney disease (CKD), raising their risk of cardiovascular mortality to “exceptionally high” levels, according to the authors of an editorial published today in the Medical Journal of Australia.
Professor Vlado Perkovic, Executive Director of the George Institute for Global Health Australia in Sydney, and Dr Brendon Neuen, a PhD candidate, wrote that “even more striking is that the relative likelihood of cardiovascular disease-related death is substantially higher for younger patients”.
“This is particularly worrying, as the burden of type 2 diabetes in young people is rapidly increasing worldwide; in little more than a decade, the number of people aged 20–39 years with type 2 diabetes has almost tripled, rising from 23 to 63 million,” they wrote.
Clinical trials of interventions for reducing the risk cardiovascular events and mortality in patients with ESKD “have not yielded clear evidence of benefit”.
Lipid-lowering therapy is effective for patients with chronic kidney disease who do not require dialysis, and is therefore recommended in practice guidelines, but for those who do require dialysis the evidence is insufficient. Blood pressure-lowering interventions show general cardiovascular benefit, but the trials have been “inadequate” for guiding recommendations. Antiplatelet therapy is complex for people with kidney disease because of increased bleeding risk.
“The best way to improve cardiovascular outcomes for patients with ESKD is to redouble our efforts to increase the number and improve the quality of clinical trials,” wrote Perkovic and Neuen.
“We also need to urgently identify treatments that slow the loss of kidney function and prevent cardiovascular disease in people with diabetes, especially those with established nephropathy. If we do not, the rapidly growing number of people with diabetic nephropathy will inevitably translate into an increased burden of ESKD that is more complex and expensive to treat.”
There is hope in new glucose-lowering agents which reduce the risk of adverse cardiovascular events and may slow the progression of kidney disease in people with type 2 diabetes.
Perkovic and Neuen also recommended that new treatments alone were not enough to reduce the burden of diabetes and its complications.
"Multifaceted population health strategies that prevent type 2 diabetes are desperately needed to achieve the best outcomes,” they wrote. “We should embrace opportunities to take a lead role in advocating policies that recognise the environmental and behavioural drivers of diabetes and other chronic health conditions.”
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