From 1988 to 2014, no significant change occurred in the overall prevalence of diabetic kidney disease, but opposing trends were seen in its major subtypes, researchers said.
In an analysis of National Health and Nutrition Examination Survey (NHANES) data, impairments in estimated glomerular filtration rate (eGFR) became more common while albuminuria became less so, according to Maryam Afkarian, MD, PhD, of the University of Washington in Seattle, and colleagues writing in the Journal of the American Medical Association.
Rates of albuminuria during the four periods, with 6,251 participants overall, were as follows:
- 1988-1994: 20.8% (95% CI 16.3% to 25.3%)
- 1999-2004: 18.9% (95% CI 15.3% to 22.4%)
- 2005-2008: 17.9% (95% CI 14.0 to 21.9%)
- 2009-2014: 15.9% (95% CI 12.7% to 19.0%)
But over the same intervals, prevalence of reduced eGFR significantly increased:
- 1988-1994: 9.2% (95% CI 6.2% to 12.2%)
- 1999-2004: 11.6% (95% CI 8.5% to 14.6%)
- 2005-2008: 11.8% (95% CI 8.4% to 15.1%)
- 2009-2014: 14.1% (95% CI 11.3% to 17.0%)
These trends appeared to cancel each other out, as the prevalence of diabetic kidney disease overall -- defined as persistent albuminuria and/or persistent reduced eGFR -- did not change significantly over the four periods:
- 1988-1994: 28.4% (95% CI 23.8% to 32.9)
- 1999-2004: 27.3% (95% CI 23.1% to 31.4%)
- 2005-2008: 27.1% (95% CI 22.6% to 31.4%)
- 2009-2014: 26.2% (95% CI 22.6% to 29.9%)
Prevalence for severely reduced eGFR also rose during the 26-year study period (adjusted prevalence ratio 2.86 for the final period versus the first; 95% CI 1.38 to 5.91, P=0.004).
Furthermore, the authors noted a temporal trend in prevalence for albuminuria in terms of age and race/ethnicity, with the lowest rates seen in non-Hispanic whites younger than 65.
"Diabetes is the most common cause of end stage renal disease in the U.S., so understanding, preventing, and treating diabetic kidney disease is critical to reduce the numbers of people needing dialysis and kidney transplants," wrote Ian de Boer, MD, in an email to MedPage Today, "There have been major changes in the treatment of patients with diabetes over the last 30 years, so we were interested in evaluating how diabetic kidney disease was changing in this context."
NHANES participants included in the analysis were those 20 and older with type 1 or 2 diabetes, identified by use of a glucose-lowering medication (insulin or oral) when data were collected, and/or had a hemoglobin A1C of 6.5% or greater.
Albuminuria was identified by a urine albumin-to-creatinine ratio (ACR) of 30 mg/g or greater, which macroalbuminuria was classified as a urine ACR of 300 mg/g or greater. Cutoffs for reduced and severely reduced eGFR were set at 60 and 30 mL/min/1.73m2, respectively.
Because chronic kidney disease is most commonly caused by diabetes, the authors indicated their goal was "to identify priorities for DKD screening, target implementation of existing interventions, and design clinical trials for new treatments." Since the researchers found no significant change in the prevalence of diabetic kidney disease over the 26-year study period, they suggest new therapies are needed.
Limits to the study included lack of data identifying the causes of diabetic kidney disease. Additionally, the authors noted that the relatively small sample size of adult with type 1 diabetes was another limitation, such that the results mostly reflect trends in type 2 disease.
While the study was successful at including a large number of participants representative of the greater U.S. population, the authors note that future research is needed to show identify other potential factors contributing to chronic kidney disease other than diabetes.
"We need to understand the biology that's underlying the changes observed in this study. For example, what's going on in the kidneys of a patient with diabetes who has reduced GFR but no evidence of albuminuria?" de Boer told MedPage Today in an email.
"If we can understand the mechanisms of disease in today's patients, who are already often treated with good glucose and blood pressure control, then we can develop new, additional interventions to further reduce diabetic kidney disease. Advances in technology, including discovery technologies like proteomics, metabolomics, and genomics, have advanced rapidly and may help us gain this level of understanding."
The study was funded by grants from the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Clinical and Translational Sciences, components of the National Institutes of Health, the American Diabetes Association, and Northwest Kidney Centers.
Tuttle disclosed relevant relationships with Eli Lilly, Amgen, Noxxon Pharma, and Boehringer-Ingelheim.
De Boer disclosed relevant relationships with Bayer, Boehringer-Ingelheim, Ironwood, Amgen, and Janssen.
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