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Yang X, Xue C, Chen K, Gao D, Wang H, Tang C. Characteristics of elderly diabetes patients: focus on clinical manifestation, pathogenic mechanism, and the role of traditional Chinese medicine. Front Pharmacol 2024; 14:1339744. [PMID: 38273819 PMCID: PMC10808572 DOI: 10.3389/fphar.2023.1339744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/28/2023] [Indexed: 01/27/2024] Open
Abstract
Diabetes mellitus has become a major public health issue globally, putting an enormous burden on global health systems and people. Among all diseased groups, a considerable part of patients are elderly, while their clinical features, pathogenic processes, and medication regimens are different from patients of other ages. Despite the availability of multiple therapies and techniques, there are still numerous elderly diabetes patients suffering from poor blood glucose control, severe complications, and drug adverse effects, which negatively affect the quality of life in their golden years. Traditional Chinese Medicine (TCM) has been widely used in the treatment of diabetes for several decades, and its relevant clinical practice has confirmed that it has a satisfactory effect on alleviating clinical symptoms and mitigating the progression of complications. Chinese herbal medicine and its active components were used widely with obvious clinical advantages by multiple targets and signaling pathways. However, due to the particular features of elderly diabetes, few studies were conducted to explore Traditional Chinese Medicine intervention on elderly diabetic patients. This study reviews the research on clinical features, pathogenic processes, treatment principles, and TCM treatments, hoping to provide fresh perspectives on the prevention and management strategies for elderly diabetes.
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Affiliation(s)
- Xiaofei Yang
- Beijing University of Chinese Medicine, Beijing, China
- Institute of Metabolic Diseases, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Chongxiang Xue
- Beijing University of Chinese Medicine, Beijing, China
- Institute of Metabolic Diseases, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Keyu Chen
- Institute of Metabolic Diseases, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dongyang Gao
- Institute of Metabolic Diseases, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Han Wang
- Beijing University of Chinese Medicine, Beijing, China
| | - Cheng Tang
- Beijing University of Chinese Medicine, Beijing, China
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Pratley RE, Cannon CP, Cherney DZI, Cosentino F, McGuire DK, Essex MN, Lawrence D, Jones PLS, Liu J, Adamsons I, Dagogo-Jack S. Cardiorenal outcomes, kidney function, and other safety outcomes with ertugliflozin in older adults with type 2 diabetes (VERTIS CV): secondary analyses from a randomised, double-blind trial. THE LANCET HEALTHY LONGEVITY 2023; 4:e143-e154. [PMID: 37003273 DOI: 10.1016/s2666-7568(23)00032-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND VERTIS CV was a randomised, double-blind, placebo-controlled, parallel-group, multicentre cardiovascular outcomes trial that evaluated the cardiovascular efficacy and safety of ertugliflozin in adults with type 2 diabetes and atherosclerotic cardiovascular disease. The primary objective of VERTIS CV was to show non-inferiority of ertugliflozin to placebo with respect to the primary outcome, major adverse cardiovascular events (a composite of death from cardiovascular causes, non-fatal myocardial infarction, or non-fatal stroke). The analyses reported here aimed to assess cardiorenal outcomes, kidney function, and other safety outcomes with ertugliflozin in older adults with type 2 diabetes and atherosclerotic cardiovascular disease compared with younger participants. METHODS VERTIS CV was done at 567 centres in 34 countries. Participants (aged ≥40 years) with type 2 diabetes and atherosclerotic cardiovascular disease were randomly assigned (1:1:1) to once-daily ertugliflozin 5 mg, ertugliflozin 15 mg, or placebo in addition to background standard-of-care treatment. Random assignment was done with the use of an interactive voice-response system. The study outcomes were major adverse cardiovascular events, hospitalisation for heart failure or cardiovascular death, cardiovascular death, hospitalisation for heart failure, prespecified kidney composite outcomes, kidney function, and other assessments of safety. Cardiorenal outcomes, kidney function, and safety outcomes were evaluated by baseline age (≥65 years and <65 years [prespecified] and ≥75 years and <75 years [post hoc]). The study is registered with ClinicalTrials.gov, NCT01986881. FINDINGS Between Dec 13, 2013, and July 31, 2015, and between June 1, 2016, and April 14, 2017, 8246 adults with type 2 diabetes and atherosclerotic cardiovascular disease were recruited to the study and randomly assigned. 2752 patients were assigned to ertugliflozin 5 mg, 2747 patients to ertugliflozin 15 mg, and 2747 patients to placebo. 8238 participants received at least one dose of ertugliflozin 5 mg, ertugliflozin 15 mg, or placebo. 4145 (50·3%) of 8238 participants were aged 65 years and older, including 903 (11·0%) participants aged 75 years and older. 5764 (70·0%) of 8238 participants were male and 2474 (30·0%) were female, and 7233 (87·8%) of 8238 participants were White, 497 (6·0%) were Asian, 235 (2·9%) were Black, and 273 (3·3%) were classified as other. The mean estimated glomerular filtration rate (eGFR) was lower and the type 2 diabetes duration longer for those aged 65 years and older versus those younger than 65 years, and for those aged 75 years and older versus those younger than 75 years. Cardiovascular outcomes were more common in the older age subgroups than in the younger age subgroups. Similar to the overall VERTIS CV cohort, ertugliflozin did not increase the risk of major adverse cardiovascular events, cardiovascular death or hospitalisation for heart failure, cardiovascular death alone, or the kidney composite outcome (using doubling of serum creatinine, dialysis or transplantation, or kidney death), and reduced the risk of hospitalisation for heart failure and the exploratory kidney composite outcome (using a 40% sustained eGFR decrease, dialysis or transplantation, or kidney death) in the older age subgroups (pinteraction>0·05 for outcomes assessed). A slower decline in eGFR and a smaller increase in the urine albumin-to-creatinine ratio were observed over time in all age subgroups taking ertugliflozin compared with placebo. Across age subgroups, safety outcomes were consistent with the known profile of ertugliflozin. INTERPRETATION The effects of ertugliflozin on cardiorenal outcomes, kidney function, and safety outcomes were generally similar across age subgroups. These results have the potential to help clinical decision making by providing a longer-term evaluation of the cardiorenal safety and overall tolerability of ertugliflozin in a large population of older adults. FUNDING Merck Sharp & Dohme LLC, a subsidiary of Merck & Co, Inc, Rahway, NJ, USA in collaboration with Pfizer Inc, New York, NY, USA.
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Chaudhuri A, Ghanim H, Arora P. Improving the residual risk of renal and cardiovascular outcomes in diabetic kidney disease: A review of pathophysiology, mechanisms, and evidence from recent trials. Diabetes Obes Metab 2022; 24:365-376. [PMID: 34779091 PMCID: PMC9300158 DOI: 10.1111/dom.14601] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/28/2021] [Accepted: 11/08/2021] [Indexed: 12/14/2022]
Abstract
Based on global estimates, almost 10% of adults have diabetes, of whom 40% are estimated to also have chronic kidney disease (CKD). Almost 2 decades ago, treatments targeting the renin-angiotensin system (RAS) were shown to slow the progression of kidney disease. More recently, studies have reported the additive benefits of antihyperglycaemic sodium-glucose co-transporter-2 inhibitors in combination with RAS inhibitors on both CKD progression and cardiovascular outcomes. However, these recent data also showed that patients continue to progress to kidney failure or die from kidney- or cardiovascular-related causes. Therefore, new agents are needed to address this continuing risk. Overactivation of the mineralocorticoid (MR) receptor contributes to kidney inflammation and fibrosis, suggesting that it is an appropriate treatment target in patients with diabetes and CKD. Novel, selective non-steroidal MR antagonists are being studied in these patients, and the results of two large recently completed clinical trials have shown that one such treatment, finerenone, significantly reduces CKD progression and cardiovascular events compared with standard of care. This review summarizes the pathogenic mechanisms of CKD in type 2 diabetes and examines the potential benefit of novel disease-modifying agents that target inflammatory and fibrotic factors in these patients.
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Affiliation(s)
- Ajay Chaudhuri
- Division of Endocrinology and MetabolismJacobs School of Medicine and Biomedical Sciences, University at BuffaloBuffaloNew YorkUSA
- Diabetes CenterKaleida HealthBuffaloNew YorkUSA
| | - Husam Ghanim
- Division of Endocrinology and MetabolismJacobs School of Medicine and Biomedical Sciences, University at BuffaloBuffaloNew YorkUSA
| | - Pradeep Arora
- Buffalo VA Medical CenterJacobs School of Medicine and Biomedical Sciences, University at BuffaloBuffaloNew YorkUSA
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Lee YT, Hsu CN, Fu CM, Wang SW, Huang CC, Li LC. Comparison of Adverse Kidney Outcomes With Empagliflozin and Linagliptin Use in Patients With Type 2 Diabetic Patients in a Real-World Setting. Front Pharmacol 2022; 12:781379. [PMID: 34992535 PMCID: PMC8724779 DOI: 10.3389/fphar.2021.781379] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/02/2021] [Indexed: 12/15/2022] Open
Abstract
Background: To compare the effects of empagliflozin and linagliptin use on kidney outcomes of type 2 diabetes mellitus (T2DM) patients in a real-world setting. Methods: The study involved a propensity score-matched cohort comprising new users of empagliflozin or linagliptin with T2DM between January 1, 2013 and December 31, 2018 from a large healthcare delivery system in Taiwan. Clinical outcomes assessed: acute kidney injury (AKI), post-AKI dialysis, and mortality. Cox proportional hazard model was used to estimate the relative risk of empagliflozin or linagliptin use; a linear mixed model was used to compare the average change in estimated glomerular filtration rate (eGFR) over time. Results: Of the 7,042 individuals, 67 of 3,521 (1.9%) in the empagliflozin group and 144 of 3,521 (4.1%) in the linagliptin group developed AKI during the 2 years follow-up. Patients in the empagliflozin group were at a 40% lower risk of developing AKI compared to those in the linagliptin group (adjusted hazard ratio [aHR], 0.60; 95% confidence interval [CI], 0.45-0.82, p = 0.001). Stratified analysis showed that empagliflozin users ≥65 years of age (aHR, 0.70; 95% CI, 0.43-1.13, p = 0.148), or with a baseline eGFR <60 ml/min/1.73 m2 (aHR, 0.97; 95% CI, 0.57-1.65, p = 0.899), or with a baseline glycohemoglobin ≦7% (aHR, 1.01; 95% CI, 0.51-2.00, p =0.973) experienced attenuated benefits with respect to AKI risk. A smaller decline in eGFR was observed in empagliflozin users compared to linagliptin users regardless of AKI occurrence (adjusted β = 1.51; 95% CI, 0.30-2.72 ml/min/1.73 m2, p = 0.014). Conclusion: Empagliflozin users were at a lower risk of developing AKI and exhibited a smaller eGFR decline than linagliptin users. Thus, empagliflozin may be a safer alternative to linagliptin for T2DM patients.
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Affiliation(s)
- Yueh-Ting Lee
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chung-Ming Fu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shih-Wei Wang
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiang-Chi Huang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Lung-Chih Li
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Pratley R, Dagogo-Jack S, Charbonnel B, Patel S, Hickman A, Liu J, Tarasenko L, Pong A, Ellison MC, Huyck S, Gantz I, Terra SG. Efficacy and safety of ertugliflozin in older patients with type 2 diabetes: A pooled analysis of phase III studies. Diabetes Obes Metab 2020; 22:2276-2286. [PMID: 32700421 DOI: 10.1111/dom.14150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/13/2020] [Accepted: 07/21/2020] [Indexed: 01/08/2023]
Abstract
AIM To assess the efficacy and safety of ertugliflozin in older patients with type 2 diabetes (T2D). MATERIALS AND METHODS This is a post hoc analysis of patients with T2D aged less than 65 years and those aged 65 years or older who participated in randomized, double-blind, phase III studies of ertugliflozin. Efficacy was evaluated in a pooled analysis of three placebo-controlled studies (ertugliflozin monotherapy and add-on therapy). Safety was evaluated in a pooled analysis of seven placebo- and active-controlled studies (including those used for efficacy). Least-squares mean change from baseline was calculated for HbA1c, fasting plasma glucose (FPG), body weight (BW) and systolic blood pressure (SBP). Safety evaluation included overall and prespecified adverse events (AEs). RESULTS In participants aged less than 65 years, the placebo-adjusted mean changes from baseline in HbA1c, BW and SBP with ertugliflozin 5 and 15 mg at week 26 were -0.9% and -1.0%, -1.9 and -1.8 kg, and -3.7 and -3.6 mmHg, respectively; in participants aged 65 years or older they were -0.6% and -0.8%, -1.9 and -2.2 kg, and -2.7 and -3.4 mmHg, respectively. The incidences of AEs, serious AEs, discontinuations and deaths in participants aged less than 65 years and those aged 65 years or older were generally similar across the treatment groups. In patients aged 65 years or older the incidences of volume depletion AEs and genital mycotic infection were higher with ertugliflozin than with non-ertugliflozin. CONCLUSIONS Ertugliflozin improved glycaemic control, BW and SBP in younger and older individuals with T2D and was generally well tolerated in both groups.
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Affiliation(s)
- Richard Pratley
- AdventHealth Translational Research Institute for Metabolism and Diabetes, Orlando, Florida, USA
| | | | | | | | | | - Jie Liu
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | - Annpey Pong
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | - Susan Huyck
- Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Ira Gantz
- Merck & Co., Inc., Kenilworth, New Jersey, USA
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Raji A, Xu ZJ, Lam RLH, O'Neill EA, Kaufman KD, Engel SS. Efficacy and Safety of Sitagliptin Compared with Dapagliflozin in People ≥ 65 Years Old with Type 2 Diabetes and Mild Renal Insufficiency. Diabetes Ther 2020; 11:2419-2428. [PMID: 32852696 PMCID: PMC7509009 DOI: 10.1007/s13300-020-00907-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Older patients with type 2 diabetes (T2D) are at increased risk of diabetic nephropathy and mild renal insufficiency. This analysis compared the anti-hyperglycemic efficacy and safety of sitagliptin with dapagliflozin in patients ≥ 65 years of age with T2D and mild renal insufficiency. METHODS This was a post hoc analysis of data from 410 patients ≥ 65 years old who participated in a 24-week, randomized, double-blind clinical trial (CompoSIT-R [comparison of sitagliptin with dapagliflozin in mild renal impairment]; NCT02532855) in T2D patients with mild renal insufficiency and on metformin ± a sulfonylurea; the primary efficacy end point was change in HbA1c at week 24. RESULTS Treatment groups were well balanced at baseline (mean HbA1c = 7.7/7.7% and eGFR = 79/76 ml/min/1.73 m2 for sitagliptin/dapagliflozin). At week 24, LS mean (95% CI) change in HbA1c and percentage of patients with HbA1c < 7% were greater with sitagliptin, - 0.48% and 41%, respectively, compared with dapagliflozin, - 0.36% and 28%; between-group differences = - 0.12% (- 0.36, 0.01) and 12.8% (3.3, 22.2) for change in HbA1c and percentage with HbA1c < 7%, respectively. The sitagliptin group had greater reductions in PPG end points, while the dapagliflozin group had greater reductions in FPG. Treatments were generally well tolerated. There were fewer drug-related adverse events (AEs) with sitagliptin than with dapagliflozin but AE profiles were otherwise similar. CONCLUSIONS In patients ≥ 65 years of age with T2D and mild renal insufficiency with inadequate glycemic control on metformin ± sulfonylurea, treatment with sitagliptin for 24 weeks resulted in improvement in HbA1c relative to treatment with dapagliflozin that is consistent with that previously observed in the overall population. Both treatments were generally well tolerated.
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Hamroun A, Frimat M, Beuscart JB, Buob D, Lionet A, Lebas C, Daroux M, Provôt F, Hazzan M, Boulanger É, Glowacki F. [Kidney disease care for the elderly]. Nephrol Ther 2019; 15:533-552. [PMID: 31711751 DOI: 10.1016/j.nephro.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.
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Affiliation(s)
- Aghilès Hamroun
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marie Frimat
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | | | - David Buob
- Service d'anatomopathologie, Centre de biologie-pathologie, CHRU de Lille, 59037 Lille, France
| | - Arnaud Lionet
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Céline Lebas
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Maïté Daroux
- Service de néphrologie, hôpital Duchenne, allée Jacques Monod, 62200 Boulogne-sur-Mer, France
| | - François Provôt
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Marc Hazzan
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France
| | - Éric Boulanger
- Service de gériatrie, CHRU de Lille, 59037 Lille, France
| | - François Glowacki
- Service de néphrologie, hôpital Huriez, CHRU de Lille, 59037 Lille, France.
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Abstract
PURPOSE OF REVIEW Older adults often live with chronic disease including diabetes and its complications. In this review, we examine the complexity and heterogeneity of older adults with diabetes and chronic kidney disease, explore the nuances in their diabetes-related monitoring, and discuss their best diabetes management. RECENT FINDINGS Although there remains an overall lack of studies in older adults with diabetes and chronic kidney disease, recent reports have highlighted their vulnerabilities. These individuals face an increased risk of cognitive impairment and dementia, frailty, dysglycemia, polypharmacy, declining kidney function, and acute kidney injury. Their diabetes management should focus upon safer antihyperglycemic medications, close monitoring, and care individualization. Older adults with diabetes and chronic kidney disease are a complex population who requires careful diabetes management and monitoring. Research efforts might focus on improving the care and outcomes of these patients.
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Affiliation(s)
- Kristin K Clemens
- Department of Medicine, Division of Endocrinology, Western University, London, Ontario, Canada.
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.
- St. Joseph's Health Care London, London, Ontario, Canada.
- Institute for Clinical Evaluative Sciences, Ontario, Canada.
- Lawson Health Research Institute, London, Ontario, Canada.
| | - Niamh O'Regan
- St. Joseph's Health Care London, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- Department of Medicine, Division of Geriatric Medicine, Western University, London, Ontario, Canada
| | - Jinnie J Rhee
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
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Piccoli GB, Ventrella F, Capizzi I, Vigotti FN, Mongilardi E, Grassi G, Loi V, Cabiddu G, Avagnina P, Versino E. Low-Protein Diets in Diabetic Chronic Kidney Disease (CKD) Patients: Are They Feasible and Worth the Effort? Nutrients 2016; 8:E649. [PMID: 27775639 PMCID: PMC5084036 DOI: 10.3390/nu8100649] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/11/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022] Open
Abstract
Low-protein diets (LPDs) are often considered as contraindicated in diabetic patients, and are seldom studied. The aim of this observational study was to provide new data on this issue. It involved 149 diabetic and 300 non-diabetic patients who followed a LPD, with a personalized approach aimed at moderate protein restriction (0.6 g/day). Survival analysis was performed according to Kaplan-Meier, and multivariate analysis with Cox model. Diabetic versus non-diabetic patients were of similar age (median 70 years) and creatinine levels at the start of the diet (2.78 mg/dL vs. 2.80 mg/dL). There was higher prevalence of nephrotic proteinuria in diabetic patients (27.52% vs. 13.67%, p = 0.002) as well as comorbidity (median Charlson index 8 vs. 6 p = 0.002). Patient survival was lower in diabetic patients, but differences levelled off considering only cases with Charlson index > 7, the only relevant covariate in Cox analysis. Dialysis-free survival was superimposable in the setting of good compliance (Mitch formula: 0.47 g/kg/day in both groups): about 50% of the cases remained dialysis-free 2 years after the first finding of e-GFR (estimated glomerular filtration rate) < 15 mL/min, and 1 year after reaching e-GFR < 10 mL/min. In patients with type 2 diabetes, higher proteinuria was associated with mortality and initiation of dialysis. In conclusion, moderately restricted LPDs allow similar results in diabetic and non non-diabetic patients with similar comorbidity.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
- Nephrologie, Centre Hospitalier Le Mans, Le Mans 72100, France.
| | - Federica Ventrella
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Irene Capizzi
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Federica N Vigotti
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Elena Mongilardi
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Giorgio Grassi
- SCDU Endocrinologia, Diabetologia e Metabolismo, Città della Salute e della Scienza Torino, Torino 10100, Italy.
| | - Valentina Loi
- SC Nefrologia, Brotzu Hospital, Cagliari 09134, Italy.
| | | | - Paolo Avagnina
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
| | - Elisabetta Versino
- SSD Epidemiology, Department of Clinical and Biological Sciences, University of Torino, Torino 10100, Italy.
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Yuen SK, Suen HP, Kwok OL, Yong SP, Tse MW. Advance care planning for 600 Chinese patients with end-stage renal disease. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.hkjn.2016.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Perl S, Cook W, Wei C, Iqbal N, Hirshberg B. Saxagliptin Efficacy and Safety in Patients With Type 2 Diabetes and Moderate Renal Impairment. Diabetes Ther 2016; 7:527-35. [PMID: 27402391 PMCID: PMC5014790 DOI: 10.1007/s13300-016-0184-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Type 2 diabetes (T2D) is the leading cause of chronic kidney disease (CKD). The recommended dose of the dipeptidyl peptidase-4 inhibitor saxagliptin is 2.5 mg in patients with moderate or severe renal impairment (creatinine clearance ≤50 mL/min). In this post hoc analysis, we assessed the effect of saxagliptin 2.5 and 5 mg/day versus placebo on glycemic measures in patients with T2D and estimated glomerular filtration rate 45-60 mL/min/1.73 m(2). METHODS Efficacy and safety data were pooled from nine 24-week, randomized, placebo-controlled clinical trials. RESULTS The majority (56-61%) of patients were women aged <65 years with glycated hemoglobin (A1C) 8.1-8.2%; half of the patients had a T2D duration ≥5 years. Mean change from baseline in A1C was significantly greater with saxagliptin 2.5 (-0.6%, P = 0.036 vs placebo) and 5 mg/day (-0.9%, P < 0.001 vs placebo) compared with placebo (-0.2%). There were numerically greater reductions in fasting plasma glucose and 2-h postprandial glucose, and a significantly greater proportion of patients achieved A1C <7% with saxagliptin 5 mg/day (44.8%) compared with placebo (20.0%, P = 0.004 vs placebo). The incidence of hypoglycemia was not significantly different across groups (16.2% in the saxagliptin 5-mg/day, 12.2% in the saxagliptin 2.5-mg/day, and 11.3% in the placebo groups). CONCLUSION These results suggest that saxagliptin 2.5 and 5 mg/day improve glycemic control and are generally well tolerated in patients with T2D and moderate CKD. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT00121641, NCT00316082, NCT00698932, NCT00918879, NCT00121667, NCT00661362, NCT00313313, NCT00295633, NCT00757588. FUNDING AstraZeneca, Gaithersburg, MD, USA.
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Affiliation(s)
- Shira Perl
- AstraZeneca, One Medimmune Way, Gaithersburg, MD, USA.
| | | | - Cheryl Wei
- AstraZeneca, One Medimmune Way, Gaithersburg, MD, USA
| | - Nayyar Iqbal
- AstraZeneca, One Medimmune Way, Gaithersburg, MD, USA
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Clemens KK, Liu K, Shariff S, Schernthaner G, Tangri N, Garg AX. Secular trends in antihyperglycaemic medication prescriptions in older adults with diabetes and chronic kidney disease: 2004-2013. Diabetes Obes Metab 2016; 18:607-14. [PMID: 26939711 DOI: 10.1111/dom.12658] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/30/2015] [Accepted: 02/29/2016] [Indexed: 12/30/2022]
Abstract
AIM To examine how antihyperglycaemic medications were prescribed to older adults with diabetes and chronic kidney disease over the last decade. METHODS We conducted a population-based study of 144 252 older adults with diabetes and chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73 m(2) or receiving chronic dialysis) in Ontario, Canada. In each study quarter (3-month intervals from 1 April 2004 until 31 March 2013) we studied the proportion of treated and newly treated patients prescribed insulin, sulphonylureas, α-glucosidase inhibitors, metformin, thiazolidinediones, meglitinides and dipeptidyl peptidase-4 (DPP-4) inhibitors. We further examined prescription trends by stage of chronic kidney disease. RESULTS The mean age of patients increased slightly (from 76 to 78 years) over the study period and the percentage with comorbidities declined. Metformin was the predominant therapy prescribed (prescribed to a mean of 56.1% of treated patients). Glyburide (glibenclamide) and thiazolidinedione prescriptions decreased (glyburide prescriptions declined from 45.5 to 9.5%, rosiglitazone from 3.6 to 0.2% and pioglitazone from 1.9 to 1.7%), while gliclazide and DPP-4 inhibitor prescriptions increased (gliclazide prescriptions increased from 0.6 to 26.4%, sitagliptin from 0 to 15.3% and saxagliptin from 0 to 2.0%). Up to 48.6% of patients with stage 3a-5 chronic kidney disease or receiving chronic dialysis were prescribed glyburide, and up to 27.6% of patients with stage 4-5 disease or receiving chronic dialysis were prescribed metformin. CONCLUSIONS In patients with chronic kidney disease, there were trends towards safer antihyperglycaemic medication prescribing. A considerable number of patients, however, continue to receive medications that should be avoided.
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Affiliation(s)
- K K Clemens
- Department of Medicine, Western University, London, ON, Canada
| | - K Liu
- Institute for Clinical Evaluative Sciences, ON, Canada
| | - S Shariff
- Institute for Clinical Evaluative Sciences, ON, Canada
| | - G Schernthaner
- Department of Medicine, Rudolfstiftung Hospital, Vienna, Austria
| | - N Tangri
- Department of Medicine, Division of Nephrology, University of Manitoba, Winnipeg, MB, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Medicine, Division of Nephrology, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - A X Garg
- Department of Medicine, Western University, London, ON, Canada
- Institute for Clinical Evaluative Sciences, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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Magalhães FG, Goulart RMM. Doença renal crônica e tratamento em idosos: uma revisão integrativa. REVISTA BRASILEIRA DE GERIATRIA E GERONTOLOGIA 2015. [DOI: 10.1590/1809-9823.2015.14132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
ResumoO envelhecimento populacional, juntamente com a crescente incidência de doenças crônicas, tem contribuído para o aumento mundial da prevalência da doença renal crônica (DRC). O objetivo deste estudo foi realizar uma revisão integrativa sobre os tratamentos propostos para idosos portadores de DRC na fase não dialítica. Foi efetuada uma busca na literatura, considerando-se o período entre janeiro de 2002 e maio de 2013, nas bases de dados eletrônicas MEDLINE, LILACS, SciELO e Science Direct, a partir das palavras-chave: chronic kidney disease, treatment e elderly. Foram incluídos os artigos livremente disponíveis e completos. Inicialmente, foram identificados 215 artigos. Após a etapa de elegibilidade, 13 artigos foram incluídos nessa revisão integrativa. As intervenções terapêuticas recomendadas para a gestão da DRC incluem o controle de hipertensão arterial, diabetes e dislipidemia, alterações alimentares, redução de peso e abstinência do fumo. Em relação ao tratamento, para muitos idosos com DRC, uma abordagem individualizada centrada no paciente pode ter mais a oferecer do que a abordagem tradicional orientada na doença. Quanto ao encaminhamento precoce ao nefrologista, esse parece ser um procedimento que apresenta benefícios na gestão da doença renal. Embora haja um esforço aparente dos pesquisadores em instituir abordagens terapêuticas mais adequadas, ainda são escassas as evidências de intervenções que melhorem a sobrevida de pacientes idosos com DRC. Contudo, algumas intervenções evitam agudizações e retardam a evolução da DRC. Nesse sentido, há necessidade da realização de estudos randomizados controlados de longo prazo incluindo indivíduos idosos com DRC, a fim de se conhecer procedimentos terapêuticos mais eficazes para o controle dessa doença.
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The Effects of Survival Predictors Before Hemodialysis Initiation is Different in Adults and the Elderly. INT J GERONTOL 2015. [DOI: 10.1016/j.ijge.2014.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Musso CG, Vilas M, Onuigbo M. Nephroprevention in the oldest old with chronic kidney disease: Special considerations. World J Nephrol 2015; 4:1-5. [PMID: 25664242 PMCID: PMC4317619 DOI: 10.5527/wjn.v4.i1.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 11/07/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] Open
Abstract
Nephroprevention strategies are crucial for handling chronic kidney disease (CKD) complications, and slowing its progression. However, these preventative measures should be guided by major geriatrics principles in order to help nephrologists to adequately handle the oldest old with CKD. These geriatric concepts consist of taking into account the relevance of choosing an individualized therapy, handling clinical frailty, and keeping a geriatric perspective which means that a good quality of life is sometimes a more important therapeutic objective in octogenarians than merely prolonging life. Even though nephroprevention strategies for treating the oldest old with CKD are basically similar to those applied to younger patients such as low sodium and protein diet, optimized hemoglobin levels, blood pressure and metabolic control, the treating physician or care provider must at all times be ready to make fundamental adjustments and tweak patient care paradigms and objectives if and when the initial therapeutic options applied have caused unintended clinical consequences and complications. Additionally, the sarcopenia status should also be evaluated and treated in very old CKD patients.
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Shastry R, Adhikari MRP, Pai MRSM, Kotian S, Chowta MN, Ullal SD. Comparison of clinical profile of geriatric and nongeriatric diabetic patients. Int J Diabetes Dev Ctries 2014. [DOI: 10.1007/s13410-014-0243-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Morley JE, Phillips S, Sieber C, Stehle P, Teta D, Visvanathan R, Volpi E, Boirie Y. Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group. J Am Med Dir Assoc 2013; 14:542-59. [DOI: 10.1016/j.jamda.2013.05.021] [Citation(s) in RCA: 1068] [Impact Index Per Article: 97.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 05/29/2013] [Indexed: 12/20/2022]
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Bennett L. PATIENT INDEPENDENCE IN CHRONIC KIDNEY DISEASE AND ANAEMIA: IMPLICATIONS OF THE 2012 KDIGO GUIDELINE. J Ren Care 2013; 39:108-17. [DOI: 10.1111/j.1755-6686.2013.12010.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Lesley Bennett
- The Oxford Kidney Unit, Oxford University Hospitals NHS Trust; Oxford; UK
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Abstract
The treatment of diabetic nephropathy in elderly individuals is based primarily on data from younger age groups. However, the assumption that the same treatment approaches for the younger age groups can be uniformly applied to elderly individuals is likely to be incorrect. The cornerstones of aggressive therapy for diabetic kidney disease in general may have drawbacks in elderly patients. For example, significant risks of tight glycemic control have emerged in recent studies. Excessive decrease of blood pressure to existing targets may be unsafe in elderly individuals. Limited data do indicate that renin-angiotensin blockade may be as effective and no riskier than in middle-aged diabetic kidney patients. Until further studies are carried out, it is prudent to treat the elderly patient with similar approaches as in younger patients, but tempered by the issues reviewed in this article. There is a growing need for the development of clinical guidelines to retool CKD management in the elderly diabetic population using both current and emerging therapies.
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Management of Hypertension in People with Diabetes Mellitus: Translating the 2012 Canadian Hypertension Education Program Recommendations into Practice. Can J Diabetes 2012. [DOI: 10.1016/j.jcjd.2012.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Depending on age, duration of diabetes and glycaemic control, 20–40% of patients with type 2 diabetes will incur a moderate or severe deterioration of renal function. This will impact the choice of blood glucose-lowering therapy and require more frequent monitoring of both renal function and glycaemic control. Moderate renal impairment (glomerular filtration rate 30 – < 60 ml/min) requires consideration of dose reduction or treatment cessation for metformin, glucagon-like peptide-1 receptor agonists, some sulphonylureas and some dipeptidyl peptidase-4 inhibitors. At lower rates of glomerular filtration down to about 15 ml/min it may be appropriate to use a meglitinide, pioglitazone or certain sulphonylureas with careful consideration of dose and co-morbidities. Dipeptidyl peptidase-4 inhibitors can be used at reduced dose in patients with very low rates of glomerular filtration, and linagliptin can be used without dose reduction, and has been used in patients on dialysis. Insulin can be used at any stage of renal impairment, but the regimen and the dose must be suitably adjusted and accompanied by adequate monitoring.
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Faruque LI, Ayyalasomayajula B, Pelletier R, Klarenbach S, Hemmelgarn BR, Tonelli M. Spatial analysis to locate new clinics for diabetic kidney patients in the underserved communities in Alberta. Nephrol Dial Transplant 2012; 27:4102-9. [PMID: 22844104 DOI: 10.1093/ndt/gfs312] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Canadians with chronic diseases often live far away from healthcare facilities, which may compromise their level of care. We used a new method for selecting optimal locations for new healthcare facilities in remote regions. METHODS We used a provincial laboratory database linked to data from the provincial health ministry. From all patients with serum creatinine measured at least once between 2002 and 2008 in Alberta, Canada, we selected those with diabetes and an estimated glomerular filtration rate (eGFR) of 15-60 mL/min/1.73 m(2). We then used two methods to select potential locations for new clinics that would serve the greatest number of remote-dwelling patients: plots showing the unadjusted density of such patients per 100 km(2) and SatScan analysis presenting the prevalent clusters of patients on the basis of chronic kidney disease (CKD) rates (adjusted for population size). RESULTS We studied 32,278 patients with concomitant diabetes and CKD. A substantial number of patients (8%) resided >200 km from existing nephrologists' clinics. Density plots mapped with ArcGIS were useful for localizing a large cluster of underserved patients. However, objective assessment with SatScan technique and ArcGIS permitted us to detect additional clusters of patients in the northwest and southeast regions of Alberta--and suggested potential locations for new clinics in these areas. CONCLUSIONS Objective techniques such as SatScan can identify clusters of underserved patients with CKD and identify potential new facility locations for consideration by decision-makers. Our findings may also be applicable to patients with other chronic diseases.
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Mache S, Kusma B, Vitzthum K, Nienhaus A, Klapp BF, Groneberg DA. Analysis and evaluation of geriatricians' working routines in German hospitals. Geriatr Gerontol Int 2011; 12:108-15. [DOI: 10.1111/j.1447-0594.2011.00714.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Holstein A, Hammer C, Hahn M, Kulamadayil NSA, Kovacs P. Severe sulfonylurea-induced hypoglycemia: a problem of uncritical prescription and deficiencies of diabetes care in geriatric patients. Expert Opin Drug Saf 2011; 9:675-81. [PMID: 20553106 DOI: 10.1517/14740338.2010.492777] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Severe sulfonylurea-induced hypoglycemia (SH) remains a life-threatening and under-reported condition. We investigated the incidence of SH and clinical characteristics of patients with type 2 diabetes mellitus (T2DM) to demonstrate typical risk constellations. METHODS In a prospective population-based observational study, all consecutive cases of SH in the period 2000 - 2009 in a German area with 200,000 inhabitants were registered. Severe hypoglycemia was defined as a symptomatic event requiring treatment with intravenous glucose and was confirmed by a blood glucose measurement of < 50 mg/dl. RESULTS A mean incidence of seven episodes of SH per year and 100,000 inhabitants was registered. The 139 hypoglycemic individuals had been treated with glimepiride (n = 98), glibenclamide (n = 40) or gliquidone (n = 1). No preparation showed a constant dose-effect relationship, SH occurring within a wide dose range. The patients were characterized as follows: age 77.5 + or - 9.4 years, duration of diabetes 11 + or - 7 years, body mass index 26.3 + or - 4.9 kg/m(2), HbA1c 6.6 + or - 1.3%, creatinine clearance 46 + or - 24 ml/min with renal insufficiency in 73% and co-medication 7 + or - 3 drugs. Two-thirds of all subjects lived independently at home whereas a third were cared for by a home nursing service or received care in nursing homes. In all, 30% had participated in diabetes education programs. In 31%, systematic blood glucose monitoring was performed. CONCLUSIONS Uncritical prescription of sulfonylureas neglecting crucial contraindications - particularly renal insufficiency - and deficiencies of diabetes care contributed substantially to the risk of SH in the mainly geriatric patients. There is a need for alternative therapeutic concepts that minimize the risk of hypoglycemia in geriatric patients with T2DM.
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Affiliation(s)
- Andreas Holstein
- Lippe-Detmold Clinic, First Department of Medicine, Röntgenstr. 18, D - 32756 Detmold, Germany.
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Williams ME, Lacson E, Wang W, Lazarus JM, Hakim R. Glycemic control and extended hemodialysis survival in patients with diabetes mellitus: comparative results of traditional and time-dependent Cox model analyses. Clin J Am Soc Nephrol 2010; 5:1595-601. [PMID: 20671217 DOI: 10.2215/cjn.09301209] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVES The benefits and risks of aggressive glycemic control in diabetes mellitus complicated by end-stage kidney failure remain uncertain but have importance because of the large patient population with inferior overall prognosis. Recent large observational studies with differing methodologies reached somewhat contrasting conclusions regarding the association of hemoglobin A1c with survival in diabetic chronic hemodialysis patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study supplements the authors' previous analysis (which found no correlation) by extending the follow-up period to 3 years and using time-dependent survival models with repeated measures. Among 24,875 nationally distributed study patients, 94.5% had type 2 diabetes, allowing additional analysis in the subset with type 1 diabetes. Data were collected at baseline and every quarter to a maximum of 3 years' follow-up. RESULTS Adjusted standard and time-dependent Cox models indicated that only extremes of glycemia were associated with inferior survival. There was no effect modification by serum albumin levels, a marker of protein nutrition status, and no trend associated with random glucose measurements in a post hoc analysis. In type 1 diabetic patients, upper extreme hemoglobin A1c values indicated lower survival risk. CONCLUSIONS Sustained extremes of glycemia were only variably and weakly associated with decreased survival in this population. In the absence of randomized, controlled trials, these results suggest that aggressive glycemic control cannot be routinely recommended for all diabetic hemodialysis patients on the basis of reducing mortality risk. Physicians are encouraged to individualize glycemic targets based on potential risks and benefits in diabetic ESRD patients.
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Abstract
The kidneys are among the most prominent body organs affected by the process of aging, as both kidney morphology and function are known to change with age. However, special challenges emerge when the elderly patient also has diabetes complicated by kidney disease. Cases frequently progress from the early stages of diabetic nephropathy to advanced kidney impairment and end-stage renal disease, and the majority of patients suffer cardiovascular complications. However, many elderly patients with diabetes will lack the classic clinical features of diabetic kidney disease. Neither the efficacy nor safety of general treatment goals such as glycemic control, hypertension management and renin–angiotensin blockade have been adequately addressed in the aging diabetic kidney patient. These basic treatments for diabetic kidney disease are extrapolated from studies of mostly middle-aged individuals. Diabetic kidney guidelines do not adequately distinguish between age groups. Aggressive management must be measured against life expectancy in the elderly. The physician should be aware of these risks. Unfortunately, many elderly diabetic chronic kidney disease/end-stage renal disease patients are not prescribed the treatments that are available. Over a third of new end-stage renal disease cases among the elderly are due to diabetic kidney disease. Prognosis is poor, even for those who receive a kidney transplant.
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Affiliation(s)
- Mark E Williams
- Renal Unit, Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215, USA
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