Chronic kidney disease in the practice of an endocrinologist: approaches to diagnosis and treatment

Abstract

The prevalence of diabetes mellitus (DM) across the world has reached epidemic proportions. Although DM is already estimated to affect more than 8% of the global population (more than 450 million people), this number is projected to grow to over 700 million people by 2045. More than 40% of people with DM are likely to develop chronic kidney disease (CKD). For people with DM, CKD is a potentially devastating condition, markedly increasing the cardiovascular risk, and potentially leading to kidney failure requiring dialysis or a kidney transplant. Chronic kidney disease encompasses a broad range of disease severity and significant heterogeneity in the risks of progression to end-stage renal disease, morbidity, and mortality. Defining chronic kidney disease as based on changes in glomerular filtration rate (GFR) or albuminuria that persist at least 3 months distinguishes it from potentially preventable or reversible acute kidney injury of less than 3 months’ duration. Since 2002, this chronic kidney disease classification has led to estimated glomerular filtration rate reporting added to serum creatinine outpatient testing panels, and its incorporation into diagnosis codes. For patients with DM, prevention and screening occur mostly in primary care and endocrinology settings. Most doctors of primary care and endocrinologists advocate multifactorial DM management of DM with a focus on good glycemic control to prevent microvascular complications, including CKD, as well as yearly screening for CKD with assessment of urine albumin excretion and eGFR. Optimal management of CKD in DM is a complex, multidisciplinary, cross-functional task. It combines the treatment of DM in general practice or diabetology to the treatment of CKD in nephrological conditions. Individuals with DM and CKD are at risk for acute DM-related complications such as hypoglycemia and diabetic ketoacidosis; long-term complications such as retinopathy, neuropathy, and foot complications; the risk of kidney failure with a need for dialysis or transplantation; and in particular, the risk of cardiovascular complications, including ischemia, arrhythmia, and heart failure. Thus, the complex treatment of DM includes regular screening for these complications and management of the many cardiovascular risk factors in addition to hyperglycemia, such as hypertension, dyslipidemia, obesity, and lifestyle factors, including diet, smoking, and physical activity. The article was prepared based on the results of a lecture within the framework of the scientific and educational project «EndoSchool». The main issues of diagnosis, treatment and prevention of CKD according to modern classifications and guidelines are highlighted.