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Section A Introduction and overview of chronic kidney disease (CKD) in people with diabetes

Chronic kidney disease in people with type 2 diabetes – A learning resource for Primary C are. Section A Introduction and overview of chronic kidney disease (CKD) in people with diabetes. Objectives and background for this learning resource. Introduction:

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Section A Introduction and overview of chronic kidney disease (CKD) in people with diabetes

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  1. Chronic kidney disease in people with type 2 diabetes – A learning resource for Primary Care Section AIntroduction and overview ofchronic kidney disease (CKD)in people with diabetes

  2. Objectives and background for this learning resource Introduction: This learning resource has been developed as part of a medical education initiative supported by Janssen. The content of this slide kit has been developed by an advisory board of renal physicians, GPs and specialist nurses. The panel of experts includes members of the British Renal Society Chronic Kidney Disease (CKD) Strategy Group. Bedrock Healthcare, a medical communications agency, has provided editorial support in developing the content; Janssen has reviewed the content for technical accuracy. Educational objectives: • To provide clear and applicable clinical guidance on chronic kidney disease (CKD) in people with type 2 diabetes to primary care healthcare professionals • To advise primary healthcare professionals on what people with diabetes need to know about their own condition with relation to CKD Usability objectives: • To provide essential, relevant and up to date information in concise presentations • To enable primary healthcare professionals to locate, select and use the content of the learning resource, as appropriate to their needs • To enable secondary care experts in CKD to refer their primary care colleagues to the resource

  3. Contents overview This learning resource comprises the following 10 sections (A-E):

  4. Contents overview (cont.) This learning resource comprises the following 10 sections (F-J):

  5. Introduction and overview ofchronic kidney disease (CKD)in people with diabetes Section A

  6. Section A – 3 key learning objectives • Objectives and background to this learning resource • Key definitions used throughout the learning resource • Overview of chronic kidney disease (CKD) in type 2 diabetes, including: • The scale of the problem • CKD in people with diabetes may be PREVENTABLE not inevitable • Outcomes for people with type 2 diabetes and CKD

  7. Key definitions (slide 1 of 3)

  8. Key definitions (slide 2 of 3)

  9. Key definitions (slide 3 of 3)

  10. What is diabetic kidney disease? Diabetic kidney disease (or diabetic nephropathy) is a ‘clinical syndrome’ usually characterised by: • Persistent albuminuria • High blood pressure • Progressive decline in eGFR • Increased risk of cardiovascular mortality and morbidity

  11. There are some myths about diabetic kidney disease (slide 1 of 2)

  12. There are some myths about diabetic kidney disease (slide 2 of 2)

  13. Diabetes and CKD are both common conditions Chronic Kidney Disease (CKD) • 4.3 per 100 people aged 18+ registered at GP practices in England have been diagnosed with CKD1 • That is 246 in an average practice*2 • Data suggest an indicative benchmark rate of 7.6% for the number of adults with CKD3 Diabetes • 6.0 per 100 people aged 17+ registered at GP practices in England have been diagnosed with diabetes1 • That is 348 in an average practice†2 “Under-diagnosis is still an issue in primary care. The number of people identified on CKD registers in England is significantly below other measures of prevalence”3 Those with CKD stages 1-3 may be most at risk of under-diagnosis * Average practice of 5,721 patients aged ≥182 † Average practice of 5,805 patients aged ≥172 References: 1. Health and Social Care Information Centre. Quality and Outcomes Framework – 2012-13: Annex 1, Report tables and charts. Available at: http://www.hscic.gov.uk/article/2021/Website-Search?productid=12972&q=figure+4.1+AND+raw+prevalence+rates+for+all+qof+registers+2012%2f13&sort =Relevance&size=10&page=1&area=both#topWebsite last accessed on 12.11.14. 2. Health and Social Care Information Centre. Numbers of Patients at a GP Practice single year of age - October 2014 – GP. Available at: http://www.hscic.gov.uk/article/2021/WebsiteSearch?productid=16172&q=number+of+patients+at+a+gp+practice+single+year+of+age+october+2014&sort=Relevance&size=10&page=1&area=both#topWebsite last accessed on 12.11.14. 3. NICE Commissioning Guide CMG37. Early identification and management of chronic kidney disease in adults. July 2012. available at: https://www.nice.org.uk/guidance/cmg37/resources/non-guidance-early-identification-and-management-of-chronic-kidney-disease-in-adults-pdf Website last accessed on 06.01.15.

  14. Diabetic kidney disease is common • UK prevalence in 2011 of CKD as a result of diabetes was reported to range from 18% to >30% in all people with diabetes1 • In 2012, 25.6% of primary renal diagnoses in patients commencing renal replacement therapy (RRT) in the UK were attributed to diabetes2 • This figure rises to 28.6% in patients aged <65 years • People with diabetes have the highest rates of RRT compared with other conditions including hypertension, polycystic kidney and renal vascular disease (see graph)2 * Average practice of 5,721 patients aged ≥182 † Average practice of 5,805 patients aged ≥172 Note: RRT indicates end stage kidney disease Reference: 1. NHS Diabetes Kidney Care. Diabetes with Kidney Disease: Key Facts. 2011. Available at: www.yhpho.org.uk/resource/view.aspx?RID=105786 Website accessed on 15.01.152. The Renal Association. UK Renal Registry 2013. Available at: https://www.renalreg.org/wp-content/uploads/2014/09/Report2013.pdfWebsite last accessed on 12.11.14

  15. Who is at risk? Type 2 diabetes is up to six times more common in people of South Asian descent and up to three times more likely among people of African-Caribbean descent1 • The graphs show prevalence of self-reported doctor diagnosed diabetes in England Reference: 1. Diabetes UK. Diabetes in the UK 2012 Key statistics on diabetes’. http://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2012.pdf Website last accessed on 12.11.14

  16. Who is at risk of end stage kidney disease? Rates of RRT are higher in areas with a higher black and minority ethnic (BME) population compared with areas with a lower BME population1 North West London Yorkshire & Humber East Midlands Note: Renal Replacement Therapy (RRT) indicates end stage kidney disease Reference: 1. UK Renal Registry. The Renal Association. 2013. Available at: https://www.renalreg.org/wp-content/uploads/2014/09/Report2013.pdf Website last accessed on 12.11.14

  17. The prevalence of diabetic kidney diseaseis increasing • The rapidly increasing prevalence of diabetes worldwide virtually assures that the proportion of diabetic kidney disease will continue to rise1 • Data from 2012 showed that diabetes was the leading cause of CKD in the US1 • In the UK, according to The Renal Association UK Renal Registry 2014, the number of people on renal replacement therapy (RRT)* has increased steadily from 1997 to 20132 • In 2013, diabetes was the primary diagnosisfor15.9% of patients undergoing RRT in the UK2 Number of patients on each treatment modality of RRT at the end of each year 1997–2013 Peritoneal dialysis Home haemodialysis Haemodialysis Transplant 60,000 50,000 40,000 Number of patients 30,000 20,000 10,000 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year • Adapted from The Renal Association. UK Renal Registry 2014. *Renal replacement therapy includes peritoneal dialysis, haemodialysis and transplant. References: 1. National Kidney Foundation KDOQI Clinical Practice Guidelines for Diabetes and CKD: 2012 Update. Available at http://www.kidney.org/sites/default/files/docs/diabetes-ckd-update-2012.pdf Website last accessed on 12.11.14. 2. . The Renal Association. UK Renal Registry 2014. Available at https://www.renalreg.org/publications-reports/#reports. Website last accessed on 20.02.15.

  18. The prevalence of CKD and diabetes varies, but the general approach is the same • There is a high degree of variation in the prevalence of CKD and diabetes between GP practices in England1 • The reasons for this variation are complex, but may include under-diagnosis and population differences2 • The general approach remains the same to reduce the risk of development and progression of diabetic kidney disease: • Controlling blood glucose and blood pressure • Lifestyle interventions e.g. diet, exercise and smoking cessation Variation in raw prevalence rates (%)at GP practices for CKD and diabetesQOF registers, 2012/13 Prevalence (%) 50 0 10 20 30 40 Chronic KidneyDisease Diabetes Mellitus(Diabetes) References: 1. Health and Social Care Information Centre. Quality and Outcomes Framework – 2012-13: Annex 1, Report tables and charts. Available at: http://www.hscic.gov.uk/catalogue/PUB12262Figure 4.3. Website last accessed on 12.11.14. 2. NICE Commissioning Guide CMG37. Early identification and management of chronic kidney disease in adults. July 2012. available at: https://www.nice.org.uk/guidance/cmg37/resources/non-guidance-early-identification-and-management-of-chronic-kidney-disease-in-adults-pdf Website last accessed on 06.01.15. Adapted from Health and Social Care Information Centre. Quality and Outcomes Framework – 2012-13: Annex 1

  19. Kidney disease powerfully predicts increasedmortality in people with diabetes1 • The increased mortality risk in people with type 2 diabetes is concentrated in those with diabetes AND kidney disease1 • Without kidney disease, diabetes is not associated with a large increase in mortality risk1 • The co-existence of kidney disease and diabetes is associated with greater mortality than the sum of excess risks associated with either diabetes or kidney disease alone1 Ten-year mortality in type 2 diabetes by kidney disease manifestation 70 47.0% 60 50 23.9% 40 Standardised ten-year cumulativeincidence of mortality 17.8% 30 20 4.1% 10 0 No KidneyDisease Albuminuria Impaired GFR Albuminuria &Impaired GFR Absolute differences in mortality risk were estimated using linear regression and were adjusted for age, sex, and race. Standardised 10-year all-cause cumulative incidences were estimated for the mean levels of the covariates in the study population. The dashed line indicates mortality in people without diabetes or kidney disease (the reference group). The numbers above bars indicate excess mortality above the reference group. Error bars indicate 95% CIs. Adapted from AfkarianM, Sachs MC, Kestenbaum B, et al. J Am Soc Nephrol 24: 302–308, 2013. Reference: 1. Afkarian M, Sachs MC, Kestenbaum B, et al. J Am Soc Nephrol 24: 302–308, 2013.

  20. Intensive blood glucose control decreases the risk of developing microvascular complications† *Intensive control with sulphonylureas or insulin, versus **conventional treatment of diet only† Microvascular complications include retinopathy, nephropathy and neuropathy Reference: 1. UKPDS Group. UKPDS33. Lancet 1998;352:837-53

  21. Section A – summary Diabetic kidney disease is: • Kidney disease caused by diabetes specifically • Common • Increasing in prevalence • Associated with greatly increased mortality compared with people with diabetes who do not have diabetic kidney disease • 4.1% vs. 47.0% ten-year mortality1 • Preventable Reference: 1. Afkarian M, Sachs MC, Kestenbaum B, et al. J Am Soc Nephrol 24: 302–308, 2013.

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