Diabetic kidney disease: an ACEI (or an ARB) in the hole

Can patterns of medication use explain the increasing incidence of end stage kidney disease among people with diabetes in Australia?

AIMS

Recently, an increase in the incidence of end-stage kidney disease (ESKD) among people with type 2 diabetes (T2D) aged < 50 years and ≥ 80 years has been observed in Australia. We examined whether patterns of medication use are likely to explain these trends.

METHODS

Among National Diabetes Services Scheme registrants, we determined the annual prevalence of dispensed glucose-lowering (GL), blood-pressure-lowering (BPL) and lipid-lowering (LL) agents with ≥3, ≥6 or ≥9 dispensings per year from 2003 to 2013. Relative changes in the prevalence were determined via Poisson regression.

RESULTS

During 2003-2013, the percentage of people with T2D dispensed GL, BPL and LL agents with ≥3, ≥6 or ≥9 dispensings per year increased in all age-groups. From 2003 to 2013, GL, BPL and LL agents use with ≥3 dispensings per year increased by 17%, 8.2%, and 53%, respectively. The use of renin-angiotensin-aldosterone-system-blockers over time also increased but more slowly in those aged <60 years compared to those aged ≥80 years (6% vs 18%, p < 0.001).

CONCLUSIONS

Changes in medication use are not likely to explain increasing incidence of ESKD in younger Australians with T2D. Studies are needed to provide insights into the major drivers of the rising incidence of ESKD in this population.

Renin-Angiotensin-Aldosterone System Blockade in Diabetic Nephropathy. Present Evidences

Diabetic Kidney Disease (DKD) is the leading cause of chronic kidney disease in developed countries and its prevalence has increased dramatically in the past few decades. These patients are at an increased risk for premature death, cardiovascular disease, and other severe illnesses that result in frequent hospitalizations and increased health-care utilization. Although much progress has been made in slowing the progression of diabetic nephropathy, renal dysfunction and the development of end-stage renal disease remain major concerns in diabetes. Dysregulation of the renin-angiotensin-aldosterone system (RAAS) results in progressive renal damage. RAAS blockade is the cornerstone of treatment of DKD, with proven efficacy in many arenas. The theoretically-attractive option of combining these medications that target different points in the pathway, potentially offering a more complete RAAS blockade, has also been tested in clinical trials, but long-term outcomes were disappointing. This review examines the “state of play” for RAAS blockade in DKD, dual blockade of various combinations, and a perspective on its benefits and potential risks.