Clinical presentation of diabetic CKD may influence mortality risk
medwireNews: US research demonstrates that mortality rates have decreased over time among diabetes patients with elevated urinary albumin excretion, but have increased for those with low estimated glomerular filtration rate (eGFR) in the absence of albuminuria.
Previous research has demonstrated that the excess mortality risk in patients with diabetes is mainly observed in those with chronic kidney disease (CKD), defined as an eGFR below 60 mL/min per 1.73 m2 and/or increased urine albumin excretion (random urine albumin-to-creatinine ratio [ACR] ≥30 mg/g), explain Holly Kramer (Loyola University Chicago, Maywood, Illinois, USA) and fellow researchers.
“Our study demonstrates the potential effect that the CKD phenotype dynamics may have on mortality,” they write in Diabetes Care.
The team used data from the National Health and Nutrition Examination Surveys 1988–2006 linked to the National Death Index to analyze mortality rates in adult patients with diabetes and CKD over a 20-year period.
They found that the total number of adult diabetes patients with low eGFR, regardless of ACR status, increased from approximately 1.73 million in 1988–1994 to 4.05 million in 2007–2010, while the number of patients with low eGFR but without elevated urinary albumin increased from approximately 0.9 million to 2.4 million over the same time period.
This “reduction in albuminuria in diabetes is probably a reflection of the improved glycemic control, blood pressure control, and the increased use of [renin–angiotensin–aldosterone system] inhibitors during the past three decades,” say the researchers.
Kramer and colleagues observed a decrease in mortality rates over the study period for both the total population of patients with diabetes and those with low eGFR and elevated albumin excretion.
However, for patients with low eGFR who did not have albuminuria, mortality rates increased from 35 deaths per 1000 person–years in 1988–1994 to 51 deaths per 1000 person–years in 2003–2006. For this subgroup of patients with an ACR below 30 mg/g, hazard ratios for mortality were higher in 1999–2002 and 2003–2006 than in 1988–1994 after adjustment for factors including demographics, comorbidities, and medication, but the differences did not reach statistical significance.
Together, these findings indicate that “ACR values are decreasing in U.S. adults with diabetes, but optimal management strategies are needed to reduce mortality in those with a low eGFR and an ACR <30 mg/g,” write the study authors.
And they conclude: “Apart from targeting CKD progression in those with severely increased urinary albumin excretion […], clinical interventions and public health policies should also address the high mortality rates in adults with diabetes and low eGFR in the absence of increased urine albumin excretion.”
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