Preventing and Managing Diabetic Kidney Disease
Diabetes is the most common cause of end-stage renal disease (ESRD) in the United States.1 Protecting the diabetic kidney involves monitoring kidney function— including urinary albumin—while avoiding iatrogenic kidney damage when choosing and dosing drug therapy.
Monitor urinary albumin
The most recent guidelines from the Kidney Disease: Improving Global Outcomes (KDIGO) Work Group define chronic kidney disease (CKD) prognosis by albuminuria level as well as estimated glomerular filtration rate (eGFR) (Figure).2 Urinary albumin predicts progression to ESRD, adding predictive value to the older model using only eGFR.3-5 A urine albumin-to-creatinine ratio (UACR) is the preferred method for measuring albuminuria,2 which can be performed by the lab or by use of a urine.4,5 Testing for urinary total protein, of which albumin is one component, is not recommended due to the superior sensitivity and specificity of urinary albumin for CKD diagnosis and staging.2 Yet in 2014, urinary albumin was tested in less than half (48%) of Medicare patients with the risk factors for ESRD: diabetes and hypertension.6
Guidelines from kidney and diabetes organizations recommend less stringent targets (ie, not treating to ≤7.0%) for those at risk of hypoglycemia and/or with comorbidities.2,7 This is especially true for those patients with underlying cardiac disease or the “fragile” elderly patient.
This supplement is intended for physicians, nurses, nurse practitioners, physician assistants, CDEs, and other clinicians involved in the diagnosis and management of metabolic and endocrine disorders.
DONNA L. JORNSAY, MS, CPNP, CDE, CDTC
CHRISTINE KESSLER, CNS, ANP, BC-ADM, CDTC, FAANP
DAVIDA F. KRUGER, MSN, APRN-BC, BC-ADM
ELLEN D. MANDEL, DMH, MPA, PA-C, RDN, CDE
LUCIA M. NOVAK, MSN, ANP-BC, BC-ADM, CDTC
JOYCE ROSS, MSN, ANP, CRNP, FPCNA, FNLA
SCOTT URQUHART, PA-C, DFAAPA
KIM ZUBER, PA-C
Method of Participation
Participants should read the activity information, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a webpage that will allow you to receive your certificate of credit via email or you may print it out at that time.
The online post-test and evaluation can be accessed at https://tinyurl.com/meds16suppl
Inquiries may be directed to Global Academy for Medical Education [email protected] or (973) 290-8225.
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Cincinnati and Global Academy for Medical Education, LLC The University of Cincinnati is accredited by the ACCME to provide continuing medical education for physicians.
The University of Cincinnati designates this Live Activity for a maximum of 2.0 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Postgraduate Institute for Medicine (PIM) is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This educational activity for 1.3 contact hours is provided by Postgraduate Institute for Medicine. Pharmacotherapy contact hours are .4 for Advance Practice Registered Nurses and will be designated on your certificate.
Primary care providers are often the first point of care for diabetes and kidney disease. The Metabolic & Endocrine Disease Summit 2016, a CME/CE conference, explored the latest advances in the management of these conditions. Obesity raises the risk of many other conditions. Providers would benefit from a discussion of how to address this frequently encountered problem in clinical practice. Lipoprotein (Lp) (a) is an inherited, independent risk factor for atherosclerotic cardiovascular disease. New therapies show some promise for addressing this form of dyslipidemia. Diabetes raises the risk of major depressive disorder, and depression increases the risk of diabetic complications. Psychosocial intervention can improve glycemic control and symptoms of diabetes-related distress. Nephropathy is a common complication of diabetes but glycemic control, careful choice of medications, and regular monitoring can promote renoprotection.
Diabetes presents issues throughout a patient’s life; three touchpoints are the transition of a young adult from pediatrics to adult care, the detection and management of diabetes during pregnancy, and diabetes in the older adult. Anticipation of the relevant issues and implementation of a transition program can contribute to retaining young adults in care. Preconception counseling and early detection of diabetes can reduce the risk of adverse outcomes. Clinicians must be knowledgeable about how to balance the many complex issues to consider when establishing glycemic targets and selecting a treatment plan for an older adult with diabetes. At this writing, four new insulin-only preparations have been approved by the US Food and Drug Administration (FDA) since February 2015. The ability to differentiate these options is important for clinicians.
After reading and studying this journal supplement, participants should be better able to:
- Differentiate the many insulin options available to treat people with diabetes, and their applications in clinical practice
- Display an understanding of the contributors to and consequences of obesity, and interventions to address unhealthy weight
- Evaluate the contribution of elevated Lp (a) to vascular risk and its influence on treatment
- Apply the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) glycemic goals and pharmacologic recommendations in the context of individual patient concerns and practical limitations.
- Incorporate consideration of renal function in monitoring, medication choice, and general management of diabetes
- Understand common errors in medication choice and dosing that are associated with kidney injury, and plan how to avoid them
- Demonstrate an understanding of the effect of depression—and its treatment—on diabetes
- List tools to assess and manage depression in patients with diabetes
- Identify risks of transition of young adults with diabetes from pediatric to adult services, and list elements of successful transition
- Demonstrate familiarity with assessment and treatment recommendations for older adults with diabetes
- Detect and manage pregestational and gestational diabetes mellitus to reduce risk of complications for the mother and child during and after pregnancy
In accordance with the ACCME Standards for Commercial Support of CME, the speakers for this course have been asked to disclose to participants the existence of any financial interest and/or relationship(s) (e.g., paid speaker, employee, paid consultant on a board and/or committee for a commercial company) that would potentially affect the objectivity of his/her presentation or whose products or services may be mentioned during their presentation. The following disclosures were made:
Planning Committee Members
Susan P. Tyler No Relevant Relationships
Rick Ricer, MD No Relevant Relationships
Eileen McCaffrey No Relevant Relationships
Sylvia Reitman No Relevant Relationships
Shirley Jones No Relevant Relationships
The following PIM planners and managers, Judi Smelker-Mitchek, RN, BSN, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, and Jan Schultz, RN, MSN, CHCP, hereby state that they or their spouse/ life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
Donna L. Jornsay, MS, CPNP, CDE, CDTC, has indicated that she is a Consultant for Becton, Dickinson and Company and Eli Lilly; a Shareholder of Medtronic Diabetes; and is on the Speaker’s Bureau for Insulet.
Christine Kessler, CNS, ANP, BC-ADM, CDTC, FAANP, is a Consultant for AstraZeneca, Medtronic, and Novo Nordisk; and is on the Speaker’s Bureau for Novo Nordisk.
Davida F. Kruger, MSN, APRN-BC, BC-ADM, has indicated that she is on the Advisory Board of Abbott, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk; and Intarcia; on the Speaker’s Bureau for Abbott, Astra Zeneca, Boehringer Ingelheim, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk, Valeritas; has stock in Dexcom; and received grants/research support from Astra Zeneca, Dexcom, Eli Lilly, Helmsley Foundation, Lexicon, and Novo Nordisk, and receives research support of 40% salary from NIH.
Ellen D. Mandel, DMH, MPA, PA-C, RDN, CDE, has nothing to disclose.
Lucia M. Novak, MSN, ANP-BC, BC-ADM, CDTC, has indicated that she is on the Speaker’s Bureau for AstraZeneca, Janssen Pharmaceuticals, and Novo Nordisk.
Joyce Ross, MSN, ANP, CLS, CRNP, FPCNA, FNLA, has indicated that she is a on the Advisory Board for Akcea Therapeutics, Kaneka America, Kastle Pharma; and on the Speaker’s Bureau for AbbVie, Amarin, Amgen, Kaneka America, KOWA, and Sanofi/Regeneron.
Scott Urquhart, PA-C, DFAAPA, has indicated that he is on the Advisory Board for AstraZeneca and Shire; a Consultant for Abbott and Acella Pharma; and on the Speaker’s Bureau for Abbott and AstraZeneca.
Kim Zuber, PA-C, has indicated that she is on the Speaker’s Bureau for Amgen and Janssen Pharmaceuticals.
All information provided by program participants is confidential and will not be shared with any other parties for any reason without permission.
Contact Information for Technical Questions
Please technical questions or concerns to Global Academy for Medical Education at 973-290-8225 or email [email protected].
The faculty acknowledge the editorial assistance of Global Academy for Medical Education, LLC, and Eileen McCaffrey, medical writer, in the development of this supplement. It has been reviewed and approved by the faculty as well as the editors of Clinical Endocrinology News.
Neither the editors of Clinical Endocrinology News nor the Editorial Advisory Board nor the reporting staff contributed to its content. The opinions expressed are those of the faculty and do not necessarily reflect the views of the supporter or of the Publisher.
Copyright © 2017 by Global Academy for Medical Education, LLC, Frontline Medical Communications Inc., and its Licensors. All rights reserved. No part of this publication may be reproduced or transmitted in any form, by any means, without prior written permission of the Publisher. Global Academy for Medical Education, LLC, will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned This continuing medical education (CME) supplement was developed from faculty presentations at the Metabolic & Endocrine Disease Summit October 5 - 8, 2016.
1. USRDS. 2016 USRDS Annual Data Report Volume 2. ESRD in the United States. Chapter 1: Incidence, prevalence, patient characteristics, and treatment modalities.
2. KDIGO 2012 Clinical practice guideline for the evaluation and management of CKD. Kidney Inter. 2013;3(Suppl 1):1-150.
3. Hallan SI, Ritz E, Lydersen S, Romundstad S, Kvenild K, Orth SR. Combining GFR and albuminuria to classify CKD improves prediction of ESRD. J Am Soc Nephrol. 2009;20(5):1069-1077. doi: 10.1681/asn.2008070730.
4. Hemmelgarn BR, Manns BJ, Lloyd A, et al. Relation between kidney function, proteinuria, and adverse outcomes. JAMA. 2010;303(5):423-429. doi: 10.1001/jama.2010.39.
5. Turin TC, James M, Ravani P, et al. Proteinuria and rate of change in kidney function in a community-based population. J Am Soc Nephrol. 2013;24(10):1661- 1667. doi: 10.1681/asn.2012111118.
6. USRDS. 2016 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. Volume 1: CKD in the United States.
7. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: A patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38(1):140-149. doi: 10.2337/dc14- 2441.
8. Bakris GL, Weir MR. Angiotensin-converting enzyme inhibitor-associated elevations in serum creatinine: Is this a cause for concern? Arch Intern Med. 2000;160(5):685-693.
9. Paige NM, Nagami GT. The top 10 things nephrologists wish every primary care physician knew. Mayo Clinic Proc. 2009;84(2):180-186. http://www.ncbi. nlm.nih.gov/pmc/articles/PMC2664589/pdf/mayoclinproc_84_2_012pdf.
10. Makani H, Bangalore S, Desouza KA, Shah A, Messerli FH. Efficacy and safety of dual blockade of the renin-angiotensin system: Meta-analysis of randomised trials. BMJ. 2013;346:f360. doi: 10.1136/bmj.f360.
11. Bhandari S, Ives N, Brettell EA, et al. Multicentre randomized controlled trial of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker withdrawal in advanced renal disease: The STOP-ACEi trial. Nephrol Dial Transplant. 2016;31(2):255-261. doi: 10.1093/ndt/gfv346.
12. FDA drug safety communication. FDA revises warnings regarding use of the diabetes medicine metformin in certain patients with reduced kidney function. April 8, 2016. Available at: https://www.fda.gov/downloads/Drugs/DrugSafety/ UCM494140.pdf. Accessed March 30, 2017.
13. Wanner C, Inzucchi SE, Lachin JM, et al. Empagliflozin and progression of kidney disease in type 2 diabetes. N Engl J Med. 2016;375(4):323-334. doi: 10.1056/NEJMoa1515920.
14. Hahr AJ, Molitch ME. Management of diabetes mellitus in patients with chronic kidney disease. Clin Diabetes Endocrinol. 2015;1(1):2. doi: 10.1186/ s40842-015-0001-9.
15. Kaakeh Y, Kanjee S, Boone K, Sutton J. Liraglutide-induced acute kidney injury. Pharmacotherapy. 2012;32(1):e7-11. doi: 10.1002/phar.1014.
16. Lopez-Ruiz A, del Peso-Gilsanz C, Meoro-Aviles A, et al. Acute renal failure when exenatide is co-administered with diuretics and angiotensin II blockers. Pharm World Sci. 2010;32(5):559-561. doi: 10.1007/s11096-010-9423-8.
17. Weise WJ, Sivanandy MS, Block CA, Comi RJ. Exenatide-associated ischemic renal failure. Diabetes Care. 2009;32(2):e22-23. doi: 10.2337/dc08-1309.
18. Marso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med. 2016;375(4):311-322. doi: doi:10.1056/NEJMoa1603827.
19. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi: 10.1001/jama.2013.284427.
20. Friedman AN, Chambers M, Kamendulis LM, Temmerman J. Short-term changes after a weight reduction intervention in advanced diabetic nephropathy. Clin J Am Soc Nephrol. 2013;8(11):1892-1898. doi: 10.2215/cjn.04010413.
21. García-Esquinas E, Loeffler LF, Weaver VM, Fadrowski JJ, Navas-Acien A. Kidney function and tobacco smoke exposure in US Adolescents. Pediatrics. 2013;131(5):e1415-e1423. doi: 10.1542/peds.2012-3201.
22. Hall ME, Wang W, Okhomina V, et al. Cigarette smoking and chronic kidney disease in African Americans in the Jackson Heart Study. J Am Heart Assoc. 2016;5(6). doi: 10.1161/jaha.116.003280.
23. Ricardo AC, Anderson CA, Yang W, et al. Healthy lifestyle and risk of kidney disease progression, atherosclerotic events, and death in CKD: Findings from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis. 2015;65(3):412-424. doi: 10.1053/j.ajkd.2014.09.016.