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

https://doi.org/10.1016/j.jdiacomp.2017.09.008Get rights and content

Abstract

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.

Introduction

A complication of diabetes mellitus (DM) is diabetic nephropathy. DM causes cirrhosis and thickening of nephrons impairing function that manifests as albuminuria, among others. Patients with chronic kidney disease (CKD) have symptoms that include headache, nausea and vomiting, reduced appetite, swelling of the limbs, itchy, and fatigue. High blood pressure (BP), or hypertension (HT), damages the blood vessels in the kidney, impairing function and often patients with diabetic nephropathy, have HT. If kidney damage is identified early, it can be slowed with treatment but once albuminuria occurs, without treatment the kidney function progressively worsens. CKD is a significant cause of morbidity in patients with DM, often leading to dialysis or kidney transplants. Treatment strategies to slow progression of kidney damage include controlling HT, and blood glucose levels and this includes medications, and lifestyle changes.1

The burden of DM is high and continues to rise, with estimates showing global prevalence of 3.8 billion people with DM in 2013 and projected to be 5.9 billion by 2035.2 The Western Pacific Region, of which Australia is part, had 1.6 billion adults (20–79 years old) in 2013 diagnosed with DM. This is projected to increase to 1.8 billion by 2040, at an estimated cost of 133 billion (Australian Dollars).3

The global prevalence of HT in adults was estimated to be 26% (972 million cases) in 2000, with most of the cases (66%) being from developing countries. Although the worldwide HT prevalence, with age-specific and sex-specific adjustments was estimated in 2005 to reach 1.56 billion by 2025,4 other estimates from 2012 had the global prevalence of HT in 2010 to have already reached 1.4 billion.5

In 2013/2014, high BP, defined as systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg, was the most frequently managed problem in Australian general practice, at a rate of 8.7 per 100 patient encounters.6 In an 2011/2012 Australian Health Survey: 1 in 3 adults had high BP; high BP was slightly more prevalent in men (34%) than women (29%); half the people who reported having high BP also had heart or circulatory conditions and 11% also had DM; and high BP increased with age.7 Also in 2011/2012, 4.6 million Australians (32%) aged > 18 years had high BP. Of these, more than two thirds (68%) had uncontrolled or unmanaged high BP (not taking medication), representing 3.1 million adult Australians.8 High BP is a well-established, modifiable risk factor for stroke and heart attack and a major contributor to chronic diseases such as chronic heart failure (CHF) and CKD. In 2003, high BP was responsible for 7.6% of the total burden of disease and injury in Australia, and accounted for more years of lost ‘healthy life’ due to disability and disease from CVD than any other biomedical risk factor in Australia.9 DM and HT are the leading causes of CKD in developed and developing countries.4

According to the 2010 Global Burden of Disease study,10 CKD was ranked 27th in the causes of global deaths in 1990 (15.7 per 100,000) and rose to 18th in 2010 (16.3 per 100,000). The prevalence of end-stage kidney disease differs across countries and regions. > 80.0% of patients receiving treatment for end-stage kidney disease are from affluent countries, with low figures reported in poor countries possibly due to patients not accessing therapy programs, thus potentially under-estimating the figure. Further, data on less symptomatic or asymptomatic early-stage CKD estimates are not clear but it is estimated that this accounts for 80–90% of CKD cases.4

The Australian prevalence of CKD, indicates that approximately 1.7 million (10.0%) people in 2011/2012 had biomedical signs of CKD.11 As discussed, DM and HT are two of the most common causes of CKD. If CKD is detected early and managed appropriately, then the otherwise inevitable deterioration in kidney function can be reduced by as much as 50% and may even be reversible.12

Section snippets

Pathophysiological mechanisms of HT in DM patients, and linkage to CKD

HT and DM are primary risk factors for atherosclerosis, and its related complications such as heart attack, stroke,13 and CKD.14 DM, HT, and CKD have substantial overlap in etiology and disease mechanism; please refer to Fig. 1: Pathophysiologic mechanisms in the development of HT in DM patients, and its subsequent link to CKD. In clinical practice DM and HT, which contribute to CKD, are found in the same patients more often than can be explained by chance alone, and the overlap between

Adhering to BP controls within an inpatient setting

Most guidelines for HT management and studies on control, mainly concentrated on the outpatient setting.100 Studies on control of HT in the inpatient hospital setting are limited, especially in patients with high-risk conditions, such as DM and CKD.100., 101., 102., 103., 104.

There has been research on control and adherence and one study105 highlighted the prevalence of BP control in 30 Finish primary health centres (hospitals). Researchers found that out of 4405 HT patients, 13% of the

Conclusion and future directions

There have been no Australian studies that considered adherence to control BP in DM and CKD patients. This is a major limitation in preventing DM and renal disease progression. It may be erroneously assumed that some clinicians are not adhering to DM, HT, and glucose recommendations, thus resulting in reduced patient outcomes. In this review, we surmise that the issue of compliance is rather complex and there are barriers to adherence. Recognising international trends in adherence to BP and

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    Conflict of interest: We have no conflicts of interest to declare. This includes that we have no financial or other interest in the product or distributor of the product. Furthermore, we have no associations, such as consultancies, stock ownership, or other equity interests or patent-licensing arrangements, to disclose. We have no sources of outside support for research: including funding, equipment, and drugs.

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