Q: I have many diabetic patients who do not monitor their blood sugars or watch their diet. I try to encourage them to manage their diabetes better to decrease their risk for kidney disease, blindness, or amputation. But they want to know what are their chances of ending up on dialysis. What percentage of patients develop kidney failure? What can I say to encourage my patients to take better care of themselves?
Diabetes is an epidemic in the United States and worldwide. It is the leading cause of chronic kidney disease and kidney failure.1 Diabetes is the primary diagnosis for about 44% of US patients who start dialysis, and hypertension for about 28%.2
Chronic kidney disease (CKD) can be viewed as a spectrum, ranging from mild (glomerular filtration rate [GFR] ≥ 60 mL/min/1.73 m2) to severe (GFR < 15 mL/min/1.73 m2, also referred to as end-stage renal disease [ESRD]).
A diabetic patient’s likelihood of developing diabetic nephropathy (DN) varies by race and geographic location. For patients with type 2 diabetes (T2DM), the rate is 5% to 10% for white patients and 10% to 20% for African-Americans.3 Hispanic patients develop DN at 1.5 times the rate among non-Hispanic whites.1 In the Pima Indians, who live primarily in Arizona, the incidence of DN approaches 60%. For patients with type 1 diabetes, the incidence of DN is 30% to 40%.1
While not all patients progress to ESRD, they are at increased risk for renal and cardiovascular complications, compared with nondiabetic patients.1 In general, about one in three patients with diabetes will develop significant nephropathy during the five to 10 years following diagnosis. For many years, microalbuminuria has been considered a predictor of renal disease progression.4
Previously, it was thought that patients with T2DM were more likely to die of cardiovascular complications than to progress to ESRD and require renal replacement therapy (RRT). However, researchers recently showed that patients with T2DM, DN, and proteinuria were more likely to progress to ESRD than to die of other complications.5
Given the alarming increase in the incidence of diabetes and diabetic kidney disease, a tool to predict the likelihood of an individual patient’s risk for kidney failure would be extremely helpful. As there are no widely accepted predictive instruments for CKD progression, providers must make ad hoc decisions about patients. This practice can result in treatment delays for patients whose disease does progress or unnecessary treatments for patients unlikely to experience kidney failure.6
In 2011, Tangri et al7 published a predictive model for patients with stages 3 to 5 CKD. The model relies on demographic data and clinical laboratory markers of CKD severity to accurately predict risk for future kidney failure. The study is available at http://jama.ama-assn.org/content/305/15/1553.long,7 and a smartphone app can be accessed at www.qxmd.com/Kidney-Failure-Risk-Equation.
To improve patient compliance, however, I would suggest the following steps:
Ask yourself, “Does my patient perceive there is a problem?” Assess the patient’s readiness to modify behavior.8
Target no more than one behavior change at each visit.
Find at least one reason to praise the patient at each visit (eg, remembering to bring his/her glucose log, keeping the scheduled appointment, initiating an exercise program, cutting down on cigarettes).
Use diabetes educators to reinforce teaching.
Suggest that your patient join the ADA. The more interested and informed patients become about this chronic illness, the more likely they are to become active participants in their own long-term care.
Wanda Y. Willis, MSN, FNP-C, CNN, Renal nurse practitioner
Washington Nephrology Associates, LLC
Takoma Park, Maryland
Q: I have a dialysis patient whose cholesterol numbers were getting quite high. I gave him a prescription for a lipid-lowering medication. He brought the prescription back, saying the nephrology AP told him it would make no difference since he was a dialysis patient. Is this true?
This is an excellent question that has been researched and debated over the past 10 years. Cardiovascular disease is the leading cause of death in patients with CKD and those in the dialysis population. So intuitively, it makes sense in these patients to control cholesterol—one of the main risk factors for cardiovascular disease. However, the research that has been done to date contradicts that hypothesis in dialysis patients.9
With a 2002 observational study, Iseki et al10 became the first researchers to document that cholesterol levels are inversely related to mortality in patients undergoing dialysis. However, this study team did not adjust for inflammation or infection—which, in addition to malnutrition, reduce HDL and LDL levels (and increase mortality).10
The goal of the Deutsche Diabetes and Dialysis (4D) trial,11 funded by a pharmaceutical company and involving 1,255 subjects, was to demonstrate the benefits of atorvastatin use in diabetic patients on dialysis. Although the agent was shown to improve patients’ lipid parameters, no statistically significant effect was found on the primary endpoints: all-cause mortality and cardiovascular and cerebrovascular events. In fact, the incidence of fatal stroke was significantly higher in the atorvastatin-treated patients, compared with those taking placebo.11
In the Evaluation of the Use of Rosuvastatin in Subjects on Regular Hemodialysis (AURORA) study,12 in which 2,776 patients were enrolled, the primary endpoint was time to major cardiovascular events (including fatal and nonfatal MI and stroke). No statistically significant changes were reported in mortality or primary or secondary endpoints in either treatment arm. However, the AURORA study did demonstrate an increased risk for fatal hemorrhagic stroke in the treatment arm.12
Most recently, in the seven-year-long Study of Heart and Renal Protection (SHARP),13 researchers investigated the benefits of cholesterol-lowering therapy, enrolling 9,270 patients with CKD and 3,023 patients undergoing dialysis. In the treatment arm of the CKD group (ie, those receiving simvastatin plus ezetimibe), a 17% reduction was reported in major atherosclerotic events. In the dialysis patients randomized to receive treatment, however, no significant reduction was found in mortality rates or cardiovascular events, compared with patients taking placebo.13
Thus, no cardioprotective benefit has yet been reported for statin use in patients receiving dialysis. In fact, these agents may increase patients’ risk for stroke. They surely increase the pill burden and treatment costs for dialysis patients. As for patients with CKD, a number of studies (including the SHARP study13) have demonstrated a benefit in statin use for primary prevention of cardiovascular events.
Susan Busch, MSN, CNP, Cleveland Clinic; Family NP Program
Kent State University, Ohio
1. CDC. 2011 National Diabetes Fact Sheet. www.cdc.gov/diabetes/pubs/estimates11.htm. Accessed May 23, 2012.
2. US Renal Data System, National Institute of Diabetes and Kidney Disease, NIH. 2010 Annual Data Report, vol II: Atlas of End-Stage Renal Disease in the United States. www.usrds.org/2010/pdf/v2_00a_intros.pdf. Accessed May 23, 2012.
3. Cowie CC, Port FK, Wolfe RA, et al. Disparities in incidence of diabetic end-stage renal disease according to race and type of diabetes. N Engl J Med. 1989;312(16):1074-1079.
4. Vora JP, Ibrahim HAA. Clinical manifestations and natural history of diabetic nephropathy. In: Johnson R, Feehally J, eds. Comprehensive Clinical Nephrology. Philadelphia, PA: Mosby; 2003:425-438.
5. Packham DK, Alves TP, Dwyer JP, et al. Relative incidence of ESRD versus cardiovascular mortality in proteinuric type 2 diabetes and nephropathy: results from the DIAMETRIC (Diabetes Mellitus Treatment for Renal Insufficiency Consortium) database. Am J Kidney Dis. 2012;59(1):75-83.
6. Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification and stratification. Ann Intern Med. 2003;139(2):137-147.
7. Tangri N, Stevens LA, Griffith J, et al. A predictive model for progression of chronic kidney disease to kidney failure. JAMA. 2011;305(15):1553-1559.
8. Prochaska JO, Velicer WF, Rossi JS, et al. Stages of change and decisional balance for 12 problem behaviors. Health Psychol. 1994;13(1):39-46.
9. Olyaei A, Lerma EV. Three strikes and statins out: a case against use of statins in dialysis patients for primary prevention. Dialysis Transplant. 2011;40(4):148-151.
10. Iseki K, Yamazato M, Tozawa M, Takishita S. Hypocholesterolemia is a significant predictor of death in a cohort of chronic hemodialysis patients. Kidney Int. 2002;61(5):1887-1893.
11. Wanner C, Krane V, März W, et al; German Diabetes and Dialysis Study Investigators. Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. N Engl J Med. 2005;353(3):238-248.
12. Fellström BC, Jardine AG, Schmeider RE, et al. Rosuvastatin and cardiovascular events in patients undergoing hemodialysis. N Engl J Med. 2009; 360(14):1395-1407.
13. SHARP Collaborative Group. Study of Heart and Renal Protection (SHARP): randomized trial to assess the effects of lowering low-density lipoprotein cholesterol among 9,438 patients with chronic kidney disease. Am Heart J. 2010;160(5):785-794.