The Management of Diabetes Mellitus in Patients with Chronic Kidney Disease: A Population-Based Study in Southern Italy

Hypertension accelerates the development of a diabetic nephropathy model with more relevant clinical features in Dahl salt-sensitive rat

OBJECTIVE

Diabetic nephropathy is becoming an increasing health problem and the major cause of chronic kidney disease. The lack of experimental models that reproduce all structural and functional alterations of human diabetic nephropathy is one of the barriers to solve these clinical needs in basic research. We aimed to establish a simple and rapid method for diabetic nephropathy induction in Dahl salt-sensitive rats and achieved more clinical relevant features.

METHODS AND RESULTS

Six or seven-week-old male Dahl salt-sensitive rats were used to induce diabetes by a single injection of streptozotocin (STZ; 45 mg/kg, intraperitoneally). After 7 days, rats with diabetes (will refer as STZ-DS rats) will be used for further studies. STZ-DS rats will be grouped and were fed with water or water containing 0.3%/0.9%/2% NaCl and a regular chow throughout the study. We found that STZ-treated Dahl salt-sensitive rat fed with 0.9% NaCl in drinking water (STZ-DS + 0.9% NaCl) displayed most of the characteristics of human diabetic nephropathy and the model meets the criteria of the diabetic nephropathy standards proposed by Animal Models of Diabetic Complications Consortium (AMDCC); which includes a 10-fold increase in albuminuria, more than 50% decline in estimated glomerular filtration rate over the lifetime, hypertrophy, thickening of the glomerular basement membrane, expansion of the mesangial matrix, any degree of arteriolar hyalinosis, severe glomerulosclerosis, and tubulointerstitial fibrosis.

CONCLUSION

STZ-DS + 0.9% NaCl is an improved diabetes nephropathy model and more suited for the study of the signaling pathways and mechanisms in the progression of diabetes-induced renal disease. The model will facilitate the development of new therapies for diabetes nephropathy.

Kidney Disease in Diabetic Patients: From Pathophysiology to Pharmacological Aspects with a Focus on Therapeutic Inertia

Diabetes mellitus represents a growing concern, both for public economy and global health. In fact, it can lead to insidious macrovascular and microvascular complications, impacting negatively on patients' quality of life. Diabetic patients often present diabetic kidney disease (DKD), a burdensome complication that can be silent for years. The average time of onset of kidney impairment in diabetic patients is about 7-10 years. The clinical impact of DKD is dangerous not only for the risk of progression to end-stage renal disease and therefore to renal replacement therapies, but also because of the associated increase in cardiovascular events. An early recognition of risk factors for DKD progression can be decisive in decreasing morbidity and mortality. DKD presents patient-related, clinician-related, and system-related issues. All these problems are translated into therapeutic inertia, which is defined as the failure to initiate or intensify therapy on time according to evidence-based clinical guidelines. Therapeutic inertia can be resolved by a multidisciplinary pool of healthcare experts. The timing of intensification of treatment, the transition to the best therapy, and dietetic strategies must be provided by a multidisciplinary team, driving the patients to the glycemic target and delaying or overcoming DKD-related complications. A timely nephrological evaluation can also guarantee adequate information to choose the right renal replacement therapy at the right time in case of renal impairment progression.

Chronic Kidney Disease Management in General Practice: A Focus on Inappropriate Drugs Prescriptions

Nephrotoxic drugs prescriptions are often prescribed inappropriately by general practitioners (GPs), increasing the risk of chronic kidney disease (CKD). The aim of this study was to detect inappropriate prescriptions in patients with CKD and to identify their predictive factors. A retrospective study on patients with creatinine values recorded in the period 2014-2016 followed by 10 GPs was performed. The estimated glomerular filtration rate (eGFR) was used to identify CKD patients. The demographic and clinical characteristics and drugs prescriptions were collected. A descriptive analysis was conducted to compare the characteristics and logistic regression models to estimate the predictive factors of inappropriate prescriptions. Of 4098 patients with creatinine values recorded, 21.9% had an eGFR <60 mL/min/1.73m². Further, 56.8% received inappropriate prescriptions, with a significantly lower probability in subjects with at least a nephrologist visit (Adj OR 0.54 (95% CI 0.36-0.81)) and a greater probability in patients treated with more active substances (1.10 (1.08-1.12)), affected by more comorbidities (1.14 (1.06-1.230)), or with serious CKD (G4/G5 21.28 (7.36-61.57)). Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most used contraindicated drugs (48.5%), while acetylsalicylic acid was the most inappropriately prescribed (39.5%). Our results highlight the inappropriate prescriptions for CKD authorized by GPs and underline the need of strategies to improve prescribing patterns.

Value For Money In The Treatment Of Patients With Type 2 Diabetes Mellitus: Assessing The Long-Term Cost-Effectiveness Of IDegLira Versus iGlarLixi In Italy

Objective

Italian treatment guidelines for type 2 diabetes mellitus (T2DM) target good glycemic control but acknowledge the associated risk of hypoglycemia. Unlike traditional antidiabetic therapies, modern treatment options such as fixed-ratio combinations of basal insulin and glucagon-like peptide 1 receptor agonists are associated with improved glycemic control, reduced body weight and low risk of hypoglycemia. The cost-effectiveness of the fixed-ratio combinations of basal insulin and glucagon-like peptide 1 receptor agonists IDegLira and iGlarLixi was assessed for Italy in patients with T2DM uncontrolled on basal insulin, to evaluate how short-term clinical benefits translate into long-term health economic outcomes.

Methods

The IQVIA CORE Diabetes Model was used to project clinical and economic outcomes over patient lifetimes. Treatment effects were sourced from an indirect treatment comparison. The analysis captured direct medical costs (expressed in 2017 Euros) from the perspective of the Italian National Health Service (NHS) and patient-related quality of life. Sensitivity analyses were performed.

Results

IDegLira was associated with gains of 0.09 life years and 0.13 quality-adjusted life years (QALYs) relative to iGlarLixi, due to a lower cumulative incidence and delayed onset of diabetes-related complications. IDegLira was associated with an incremental cost of EUR 930 over patient lifetimes, leading to an incremental cost-effectiveness ratio of EUR 7,386 per QALY gained.

Conclusion

Over the lifetime of patients with T2DM uncontrolled on basal insulin, IDegLira was associated with improved clinical outcomes at higher costs relative to iGlarLixi. At a willingness-to-pay threshold of EUR 30,000 per QALY gained, IDegLira was considered to be cost-effective versus iGlarLixi from the perspective of the Italian NHS.

Physicians' and Pharmacists' Clinical Considerations for Elderly Patients with Type 2 Diabetes Mellitus: The IMPLICA2 Study

BACKGROUND

Management of elderly patients with type 2 diabetes mellitus (T2DM) is complex due to their age-related conditions. Several clinical guidelines provide specific recommendations for management of these patients but little is known about their implementation in clinical practice.

OBJECTIVE

To describe physician and community pharmacist perceptions and routine clinical practice in the management of elderly T2DM patients.

METHODS

Cross-sectional study.

RESULTS

A total of 993 physicians and 999 community pharmacists completed the questionnaire. More physicians than pharmacists agreed on the need to establish more flexible HbA1c targets for elderly (79.4% vs. 30.6%; p < 0.001) and frail (92.6% vs. 31.4%; p < 0.001) patients than for the general diabetic population. HbA1c targets < 7.5% for elderly patients and < 8.5% for frail patients (as recommended by the principle guidelines) were set by 38.9% and 28.7% of physicians, respectively. Furthermore, 62.8% of physicians stated they follow guideline recommendations but, based on their prescription decisions for hypothetical patients, less than 50% were aligned with them. In addition, 73.1% of physicians monitor treatment adherence, mainly by using dispensing control (59.1%). Specific nutritional approaches for elderly patients are provided by 62.9% of physicians and 56.0% of pharmacists, whilst 57.4% and 21.7%, respectively, deliver specific physical exercise programs.

CONCLUSIONS

Low adherence to guideline recommendations (i.e. setting more stringent HbA1c targets or delaying treatment intensification) may lead to suboptimal glycaemic control in elderly patients. The standardization of processes, extensive monitoring of patient treatment adherence and providing advice regarding specific personal lifestyle habits may improve the management of elderly T2DM patients.

Diabetic kidney disease in the elderly: prevalence and clinical correlates

BACKGROUND

Diabetic kidney disease (DKD) is a major burden in elderly patients with type 2 diabetes (T2DM). Low estimated glomerular filtration rate (eGFR+, < 60 mL/min/1.73 m2) and albuminuria (Alb+) are essential for the diagnosis of DKD, but their association with clinical variables and quality of care may be influenced by ageing.

METHODS

Here we investigated the association of clinical variables and quality of care measures with eGFR+ and Alb+ in 157,595 T2DM individuals participating to the Italian Association of Clinical Diabetologists (AMD) Annals Initiative, stratified by age.

RESULTS

The prevalence of eGFR+ and Alb+ increased with ageing, although this increment was more pronounced for low eGFR. Irrespective of age, both the eGFR+ and Alb + groups had the worst risk factors profile when compared to subjects without renal disease, showing a higher prevalence of out-of target values of HbA1c, BMI, triglycerides, HDL-C, blood pressure and more complex cardiovascular (CVD) and anti-diabetic therapies, including a larger use of insulin In all age groups, these associations differed according to the specific renal outcome examined: male sex and smoking were positively associated with Alb+ and negatively with eGFR+; age and anti-hypertensive therapies were more strongly associated with eGFR+, glucose control with Alb+, whereas BMI, and lipid-related variables with both abnormalities. All these associations were attenuated in the older (> 75 years) as compared to the younger groups (< 65 years; 65-75 years), and they were confirmed by multivariate analysis. Notably, Q-score values < 15, indicating a low quality of care, were strongly associated with Alb+ (OR 8.54; P < 0.001), but not with eGFR+.

CONCLUSIONS

In T2DM patients, the prevalence of both eGFR and Albuminuria increase with age. DKD is associated with poor cardiovascular risk profile and a lower quality of care, although these associations are influenced by the type of renal abnormality and by ageing. These data indicate that clinical surveillance of DKD should not be unerestimated in old T2DM patients.

Blood glucose and pressure controls in diabetic kidney disease: Narrative review of adherence, barriers and evidence of achievement

AIMS

To review the epidemiology and the clinical evidence regarding achieving blood pressure (BP) and blood glucose control in patients with chronic kidney disease (CKD) and diabetes mellitus (DM), with emphasis on adherence and barriers within the context of Australian clinical guidelines. This article then considers Australian services aimed at BP, DM, and CKD, guideline adherence and control.

METHODS

Evidence from PubMed-listed articles published between 1994 and 2016 is considered, including original research, focusing on randomised controlled trials and prospective studies, review articles, meta- analyses, expert and professional bodies' guidelines as well as our experience.

RESULTS

There have been no Australian studies that consider adherence to BP control in DM and CKD patients. This is a major limitation in preventing DM and renal disease progression. It is possible that Australian clinicians are not adhering to DM, hypertension (HT), and glucose recommendations, thus resulting in reduced patient outcomes.

CONCLUSIONS

It is hoped that future studies ascertain the extent to which the required BP and glucose control in patients is achieved, and the potential barriers to adherence. The significance of this is immense since the impact of failure to control blood glucose levels and BP leads to renal damage.

Services aimed at achieving desirable clinical outcomes in patients with chronic kidney disease and diabetes mellitus: A narrative review

There is a large number of patients with chronic kidney disease (CKD), diabetes mellitus (DM), and hypertension (HT) but whether the targets on blood pressure (BP) control in patients with DM and/or CKD are met is not clear. This narrative review therefore investigated evidence on services aimed at achieving desirable clinical results in patients with CKD and DM, and HT in Australia. Literature pertaining to pathology diagnosis and management of these patients as well as the complexities in management were considered. This involved evidence from PubMed-listed articles published between 1993 and 2016 including original research studies, focusing on randomised controlled trials and prospective studies where possible, systematic and other review articles, meta- analyses, expert consensus documents and specialist society guidelines, such as those from the National Heart Foundation of Australia, American Diabetes Association, the Department of Health, The Royal College of Pathologists of Australasia, and The Australasian College of Emergency Medicine. Based on the literature reviewed, it is yet unknown as to how effective programs, such as diabetes inpatient services, endocrine out-patient services, and cardiac rehabilitation services, are at achieving guideline recommendations. It is also not clear how or whether clinicians are encumbered by complexities in their efforts of adhering to DM, HT, and glucose control recommendations, and the potential reasons for clinical inertia. Future studies are needed to ascertain the extent to which required BP and glucose control in patients is achieved, and whether clinical inertia is a barrier.

Current therapeutic approaches in the management of hyperglycemia in chronic renal disease

Diabetes mellitus (DM) and chronic kidney disease (CKD) are intricately intertwined. DM is the most common cause of CKD. Adequate control of DM is necessary for prevention of progression of CKD, while careful management of the metabolic abnormalities in CKD will assist in achieving better control of DM. Two of the key organs involved in glucose production are the kidney and the liver. Furthermore, the kidney also plays a role in glucose filtration and reabsorption. In CKD, monitoring of glycemic control using traditional methods such as Hemoglobin A1c (Hba1c) must be done with caution secondary to associated hematological abnormalities in CKD. With regard to medication management in the care of patients with DM, CKD has significant effects. For example, the dosages of oral and non-insulin anti-hyperglycemic agents often need to be modified according to renal function. Insulin metabolism is altered in CKD, and a reduction in insulin dose is almost always needed. Dialysis also affects various aspects of glucose homeostasis, necessitating appropriate changes in therapy. Due to the aforementioned factors glycemic management in patients with DM and CKD can be quiet challenging.