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Hello. I'm Professor
Merlin Thomas from
the Department of Diabetes here
at Melbourne's Monash University
and it's my pleasure to
be talking to you about
"Chronic Kidney Disease
in Type 2 Diabetes."
In the previous
module I looked at
the pathogenesis of
diabetic kidney disease,
how it occurs and why glucose
drives it and some of
the mechanisms behind
it as well as the associations
with the complications
including obviously end-stage
kidney disease there's
also cardiovascular and
other complications.
In this particular module
we're going to focus on
how chronic kidney
disease in diabetes is
actually treated and the new
recommendations regarding
the management protocols for
chronic kidney
disease in diabetes.
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Obviously when you
identify someone
with chronic kidney disease who
has diabetes there are a number
of priorities in terms
of your management.
The first most
obvious priority is
preserving what kidney
function is currently left.
Because when the GFR
declines in an individual
with diabetes,
it usually represents
an irreversible loss of
nephron mass filtering units
that maintain kidney function.
When those are lost,
it's irreversible,
they can't come back.
But what you can do
is protect what you
still have so that
further losses are
slowed and if possible
prevented by the therapy
that you initiate so that
the time it takes to develop
a severely impaired
kidney function
or essentially end-stage
kidney disease
requiring renal replacement
therapy is slowed and
if possible prevented entirely
in a patient's lifetime.
The second important goal
for treating patients
with type 2 diabetes and
chronic kidney diseases is
of course improving
their survival.
As you've heard in
the previous module
the presence and severity
of chronic kidney
disease in someone with
diabetes is a very
strong predictor of
poor outcomes including
impaired survival.
The treatment process
is essentially keeping
your patient alive
as much it is is to
preserving their
residual kidney function
and at the same time
if you're going to
keep your patients
alive the priority is to keep
them out of hospital and free of
complications that would reduce
their quality of life and
health status overall.
These three features are
intrinsically linked
there's really
no point in preserving
kidney function
if you're going to die
early or feel miserable.
Equally, if you can keep people
from feeling miserable and
preventing them to die early,
it's really important to
protect their kidney function
because you don't want them
then to end up on dialysis.
Enhancing their health and
also enhancing their
quality of life
is a critical
component of treating
type 2 diabetes and
chronic kidney disease.
Equally, when patients get to
advanced stages of
their chronic kidney
disease it's appropriate to
refer and plan for
management of end-stage
kidney disease whether that's
dialysis, kidney
transplantation or
a stage palliative
care without dialysis.
That is sometimes
appropriate for
our older and frailer patients.
But fundamentally the
most important goal and
usually the first thing
that we think are they
managing patients with
type 2 diabetes and
chronic kidney disease is
don't make things worse.
Because we understand
that patients with
type 2 diabetes and CKD
are at higher risk of
developing adverse
drug reactions and as
a result we are very risk
averse in the setting.
We tend not to initiate
new therapies in this
situation because we're always
worried that these are
the patients where adding
in something not only
doesn't give us much
gain but also gives us
much grief in terms of side
effects and complications.
