The prevalence of chronic kidney disease and screening of renal function in type 2 diabetic patients in Finnish primary healthcare

AimsTo estimate the prevalence of chronic kidney disease (CKD) in patients with type 2 diabetes (T2D) in Finnish primary healthcare, and to evaluate the screening for CKD and the proportions of patients receiving antihyperglycemic and cardiovascular preventive medication.Material and methodsT2D patients treated at the Rovaniemi Health Center, Finland during the years 2015–2019. Data included patient characteristics, blood pressure, HbA1c, lipid levels, kidney function and albuminuria, and medications prescribed. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.72 m² and/or albuminuria.ResultsThe study population comprised of 5112 T2D patients with a mean (SD) age of 66.7 (13.0) years. Of these, 60.2% were screened for CKD with both eGFR and albuminuria, and 30.1% of these patients had CKD. The prevalence of moderately increased and severely increased albuminuria was 19.6% and 3.2%, respectively. A total of 57.0% of the study population received angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB).ConclusionsScreening for CKD with both recommended measures (eGFR and albuminuria) was insufficiently performed among this T2D population. Additionally, just over half of the study population had been prescribed ACE inhibitors or ARB. These results suggest an incongruity between the gold standard of diabetes care and real-world clinical practice.     

Prevalence and risk factors of neuropathy in newly diagnosed type 2 diabetes in primary care practices: A retrospective database analysis in Germany and UK

AimsTo estimate the prevalence and risk factors of diabetic neuropathy in newly diagnosed type 2 diabetes in general practices.MethodsLongitudinal data from nationwide general practices in Germany (n = 630) and UK (n = 100) (Disease Analyzer) were analyzed. Patients with newly diagnosed (<1 year) type 2 diabetes (2008–2012) were identified including 45,633 patients (age: 66, SD: 12 years) in Germany and 14,205 patients (age: 63, SD: 13 years) in UK. Neuropathy was identified by ICD code (E11.4) or the original diagnosis. Associations of potential risk factors with neuropathy were investigated using logistic regression.ResultsThe prevalence of diagnosed neuropathy was 5.7% (95% CI: 5.5–5.9%) in Germany and 2.4% (1.9–2.9%) in UK. In Germany, factors independently associated with neuropathy in stepwise logistic regression were age (>70 years: OR; 95% CI 2.1; 1.6–2.8), retinopathy (3.0; 2.1–4.2), peripheral artery disease (PAD: 1.9; 1.4–2.5), insulin treatment (4.6; 3.5–6.2) and oral antidiabetic drugs (OAD: 1.6; 1.2–2.0). In UK, male sex (1.4; 1.01–1.9), nephropathy (1.7; 1.2–2.5), PAD (1.5; 1.1–2.1), antihypertensives (1.7; 1.1–2.5), insulin (2.1; 1.1–3.8) and OAD (1.4; 1.01–1.8) were identified.ConclusionsThe prevalence of diabetic neuropathy at time of type 2 diabetes diagnosis was low in primary care (Germany, UK). Neuropathy was associated with age, PAD and microvacular complications.     

Review of the renal endpoints used in cardiovascular safety clinical trials in type 2 diabetes mellitus patients and their importance in primary care

Chronic kidney disease (CKD) is one of the most common complications of type 2 diabetes mellitus (T2DM). Furthermore, CKD confers a considerable increase in the risk of cardiovascular (CV) morbidity and mortality. In line with the need to improve knowledge in this field, this article aims to describe the renal endpoints used in the different cardiovascular outcome trials (CVOTs). The objective is to better know the renal variables used in the different CVOTs in order to optimize the implementation of advances in the prevention of progressive diabetic kidney disease in patients with T2DM in clinical practice.     

Chronic kidney disease prevalence and cardiovascular risk in a cohort of patients with type 2 diabetes followed for 10 years in Badajoz (Spain). An observational study

AimsTo estimate the prevalence of chronic kidney disease (CKD), their risk factors the incidence of cardiovascular and coronary events and total and cardiovascular mortality in a cohort of type 2 diabetes (T2DM) patients observed for 10 years in primary care practices in Badajoz, Spain.MethodsObservational, longitudinal study. A total of 643 patients with T2DM (mean age 64.0 years, 55.7% women), without evidence of cardiovascular disease, were studied. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² at the beginning of the study, by applying the simplified Modification of Diet in Renal Disease (MDRD) Study formula.ResultsThe prevalence rate of CKD was 24.3%. Patients with CKD had higher percentages of coronary, cerebrovascular and cardiovascular events and higher rates of cardiovascular mortality (18.6 vs. 6.0%, p < 0.001) and total mortality (42.3 vs. 23.4%, p < 0.01), compared to patients without CKD. The Cox proportional hazards model, adjusted for age, systolic blood pressure levels, glycated haemoglobin, total cholesterol, obesity and smoking, revealed that patients with CKD had an increased risk of coronary events (HR:2.18; 95% CI:1.13?4.22, p < 0.05).ConclusionsOur study confirms a high prevalence of CKD in patients with T2DM and its relationship with the presence of cardiovascular disease.     

Impact of chronic kidney disease definition on assessment of its incidence and risk factors in patients with newly diagnosed type 1 and type 2 diabetes in the UK: A cohort study using primary care data from the United Kingdom

AimTo estimate the incidence and risk factors of chronic kidney disease (CKD) in patients with newly-diagnosed diabetes using different CKD definitions.MethodsUsing UK primary care data, patients with diabetes (type 1, 4691; type 2, 109,365) and no CKD were followed to identify newly-diagnosed CKD, classified by a broad and narrow CKD definition (to capture diabetes-induced CKD, termed diabetic kidney disease, DKD). Adjusted incidence rates of CKD/DKD were calculated, and risk factors identified using Cox regression.ResultsThere were 404 CKD cases and 147 DKD cases among patients with type 1 diabetes (T1D), and 29,104 CKD cases, 9284 DKD cases among patients with type 2 diabetes (T2D). Adjusted incidence rates of CKD per 100 years were 5.4 (T1D) and 5.5 (T2D); for DKD they were 1.9 and 1.5, respectively. Risk factors for CKD/DKD were older age, high social deprivation, obesity, cardiovascular disease, hypertension and smoking. Poor glycaemic control in the year after diabetes diagnosis was a strong predictor of CKD/DKD occurrence beyond this first year, and a risk factor for CKD/DKD in T2D.ConclusionsCKD and DKD remain common in diabetics in the decade after diagnosis. Early prevention of T2D and aggressive treatment of risk factors is urgent.     

Glomerular filtration rate, albuminuria and risk of cardiovascular and all-cause mortality in type 2 diabetic individuals

Background and aims

To assess all-cause and cardiovascular mortality in type 2 diabetic individuals according to estimated glomerular filtration rate (eGFR) and albuminuria.

Methods and results

We followed 2823 type 2 diabetic outpatients for a median period of 6 years for the occurrence of all-cause and cardiovascular mortality. eGFR was estimated using the abbreviated Modification of Diet in Renal Disease study equation. At baseline, an eGFR <60 ml/min/1.73 m² and abnormal albuminuria were present in 22.5% and 26.0% of participants, respectively. During follow-up, a total of 309 patients died, 53% of deaths were secondary to cardiovascular causes. Risks of all-cause and cardiovascular mortality increased progressively with decreasing eGFR and increasing albuminuria. After adjustment for age, sex, body mass index, smoking, hypertension, diabetes duration, hemoglobin A1c, plasma lipids, medications use (hypoglycemic, anti-hypertensive, anti-platelet or lipid-lowering drugs) and albuminuria, the hazard ratios of all-cause and cardiovascular mortality per 1-SD decrease in eGFR were 1.53 (95%CI 1.2-2.0; p < 0.0001) and 1.51 (95%CI 1.05-2.2; p = 0.023), respectively. A similar pattern in the risk of all-cause and cardiovascular mortality was seen for albuminuria (1.14, 1.01-1.3, p = 0.028 and 1.19, 1.01-1.4, p = 0.043 per 1-SD increase in albuminuria, respectively) after adjustment for eGFR and other potential confounders.

Conclusions

These findings suggest that both decreasing eGFR and rising albuminuria are associated with all-cause and cardiovascular mortality in type 2 diabetic individuals, independently of traditional risk factors and diabetes-related variables.     

Long-term outcomes of lifestyle intervention to prevent type 2 diabetes in people at high risk in primary health care

AimsThe Finnish National Diabetes Prevention Program (FIN-D2D) was the first large-scale diabetes prevention program in a primary health care setting in the world. The risk reduction of type 2 diabetes was 69% after one-year intervention in high-risk individuals who were able to lose 5% of their weight. We investigated long-term effects of one-year weight change on the incidence of type 2 diabetes, cardiovascular events, and all-cause mortality.MethodsA total of 10,149 high-risk individuals for type 2 diabetes were identified in primary health care centers and they were offered lifestyle intervention to prevent diabetes. Of these individuals who participated in the baseline screening, 8353 had an oral glucose tolerance test (OGTT). Complete follow-up data during one-year intervention were available for 2730 individuals and those were included in the follow-up analysis. The long-term outcome events were collected from national health registers after the median follow-up of 7.4 years.ResultsAmong individuals who lost weight 2.5?4.9% and 5% or more during the first year, the hazard ratio for the incidence of drug-treated diabetes was 0.63 (95% CI 0.49?0.81, p = 0.0001), and 0.71 (95% CI 0.56?0.90, p = 0.004), respectively, compared with those with stable weight. There were no significant differences in cardiovascular events or all-cause mortality among study participants according to one-year weight changes.ConclusionsHigh-risk individuals for type 2 diabetes who achieved a moderate weight loss by one-year lifestyle counseling in primary health care had a long-term reduction in the incidence of drug-treated type 2 diabetes. The observed moderate weight loss was not associated with a reduction in cardiovascular events.     

Anaemia, independent of chronic kidney disease, predicts all-cause and cardiovascular mortality in type 2 diabetic patients

Objective

There is limited and controversial information on whether anaemia is a risk factor for cardiovascular mortality in type 2 diabetes, and whether this risk is modified by the presence of chronic kidney disease (CKD). We assessed the predictive role of lower hemoglobin concentrations on all-cause and cardiovascular mortality in a cohort of type 2 diabetic individuals.

Methods

The cohort included 1153 type 2 diabetic outpatients, who were followed for a mean period of 4.9 years. The independent association of anaemia (i.e., hemoglobin <120 g/l in women and <130 g/l in men) with all-cause and cardiovascular mortality was evaluated by Cox proportional hazards regression models and adjusted for several potential confounders, including kidney function measures.

Results

During follow-up, 166 (14.4%) patients died, 42.2% (n = 70) of them from cardiovascular causes. In univariate analysis, anaemia was associated with increased risk of all-cause (hazard ratio HR 2.62, 95% confidence intervals 1.90–3.60, p < 0.001) and cardiovascular mortality (HR 2.70, 1.67–4.37, p < 0.001). After adjustment for age, sex, body mass index, smoking, hypertension, dyslipidemia, diabetes duration, hemoglobin A1c, medication use (hypoglycemic, anti-hypertensive, lipid-lowering and anti-platelet drugs) and kidney function measures, the association of anaemia with all-cause (adjusted HR 2.11, 1.32–3.35, p = 0.002) and cardiovascular mortality (adjusted HR 2.23, 1.12–4.39, p = 0.020) remained statistically significant.

Conclusions

Anaemia is associated with increased risk of all-cause and cardiovascular mortality in type 2 diabetic individuals, independently of the presence of CKD and other potential confounders. The advantage to treat anaemia in type 2 diabetes for reducing the risk of adverse cardiovascular outcomes remains to be demonstrated.     

Risk factor management of type 2 diabetic patients in primary care in the Scandinavian countries between 2003 and 2015

AimsTo observe and report population demography, comorbidities, risk factor levels and risk factor treatment in a sample of individuals treated for type 2 diabetes in primary care in Norway, Sweden and Denmark.MethodsRetrospective observational cohort using extraction of data from electronic medical records linked with national health care registries.ResultsSixty primary care clinics participated with annual cross-sectional data (2003 to 2015). In 2015 the sample consisted of 31,632 individuals. Mean age (64.5–66.8 years) and proportion of women (43–45%) were similar. The prevalence of cardiovascular disease in 2015 was 40.7%, 41.6% and 38.0% for Norway, Sweden and Denmark, respectively and 84% to 89% of patients were receiving a pharmacological anti-diabetic treatment. More Danish patients reached targets for HbA_1c and LDL cholesterol, while more patients in Sweden and Denmark met the blood pressure target of <130/80 mmHg as compared to Norway.ConclusionsIn three comparable public primary health care systems we found a high prevalence of cardiovascular disease and differences in risk factor treatment and attainment of risk factor goals. With recent guideline changes there is potential for further prevention of diabetes complications in primary care in the future.     

Management of obesity in patients with type 2 diabetes mellitus in primary care

AimsObesity and being overweight is the most powerful risk factor accounting for 80–90% of patients with type 2 diabetes mellitus (T2DM). The epidemic of obesity is driving the diabetes epidemic to alarming levels and primary care is becoming an important setting for obesity management in T2DM in India. Yet many primary care providers feel ill-equipped or inadequately supported to address obesity in patients with diabetes. This article reviews the most recent and strongest evidence-based strategies that may aid physicians in management of obesity in patients with T2DM in primary care.Material and methodsA systematic literature search of MEDLINE using the search terms Obesity, Obesity in T2DM, weight loss and Primary Care was conducted. The American Diabetes Association, National Institute for Health, National Institute of Health and Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and World Health Organization websites were also searched. Most studies in this area are observational in design with few randomized controlled trials (RCTs). Articles and studies involving meta-analysis or RCTs were preferred over other types.Results and conclusionEffective weight management treatment in T2DM patient can be implemented in the primary care setting. Evidence based individualized lifestyle and pharmacologic measures supported by behavioral intervention and counseling with appropriate and informed surgical referrals has the potential to improve the success of weight management within primary care.     

Long-term risk of stroke in type 2 diabetes patients with diabetic ketoacidosis: A population-based,propensity score-matched,longitudinal follow-up study

AimTo investigate the long-term risk of stroke in type 2 diabetes (T2D) patients with previous episodes of diabetic ketoacidosis (DKA).MethodsThis retrospective nationwide population-based cohort study was conducted using Taiwan's National Health Insurance database. Claims data from 2000 to 2002 were extracted for 3572 T2D patients with DKA and 7144 controls matched for age, gender, diabetes complications severity index, frequency of clinical visits and baseline comorbidities. Patients with type 1 diabetes (T1D), identified by glucagon C-peptide stimulation or glutamic acid decarboxylase (GAD) antibody blood tests and possession of a catastrophic illness certificate were excluded. All patients were tracked until a new stroke diagnosis, death or the end of 2011.ResultsOf the 3572 selected patients, 270 with DKA and 404 of the 7144 controls were diagnosed with a new stroke, giving an incidence rate ratio (IRR) of 1.56 (95% CI: 1.34–1.82; P < 0.0001). DKA patients had a higher risk of ischaemic stroke than those without DKA (IRR: 1.62, 95% CI: 1.34–1.96; P < 0.0001), and DKA patients with hypertension and hyperlipidaemia were at even greater risk of stroke. Also, DKA patients were at particular risk for stroke during the first half-year following DKA diagnosis. After adjusting for patient characteristics and comorbidities, these patients were 1.55 times more likely to have a stroke than those without DKA (95% CI: 1.332–1.813, P < 0.0001).ConclusionT2D patients with previous DKA have a higher risk of stroke, especially ischaemic strokes.     

A quality improvement collaborative increased preventive education and screening rates for women at high-risk for type 2 diabetes mellitus in primary care settings

AimsType 2 diabetes mellitus (T2DM) rates continue to increase across women of reproductive age in the United States. The Ohio Type 2 Diabetes Learning Collaborative aimed to improve education and screening for T2DM among women aged 18–44 years at high risk for developing T2DM.MethodsFifteen primary care practices across Ohio participated in a 12-month quality improvement (QI) collaborative, which included monthly calls to share best practices, one-on-one QI coaching, and Plan-Do-Study-Act cycles. Monthly, practices submitted data on three outcome measures on preventive education and three measures on clinical screening for T2DM.ResultsIncreases across each of the three preventive education rates (range of percent increase: 53.6% – 60.0%) and each of the three screening rates for T2DM (15.0% – 19.4%) were observed. Specifically, screening rates for high-risk women with two or more risk factors for T2DM (excluding gestational diabetes mellitus (GDM)) increased by 16.8% (60.5%–77.3%) while rates for T2DM among women with a history of GDM increased by 15.0% (75.0 – 90.0).ConclusionsA quality improvement collaborative increased preventive education and screening rates for women at high-risk for T2DM in primary care settings.     

Serum uric acid levels and diabetic kidney disease in patients with type 2 diabetes mellitus: A dose-response meta-analysis

ObjectiveOur study aimed to assess the existing evidence on whether serum uric acid (SUA) levels are associated with diabetic kidney disease (DKD) in patients with type 2 diabetes mellitus (T2DM).MethodsWe conducted a systematic search of articles up to October 2021 in Medline, Embase, The Cochrane Library and Web of Science that estimated DKD by SUA levels in patients with T2DM. Pooled relative risks with 95% CI were calculated using random effects modelsResultsA total of eight cohort studies involving 25,741 T2DM patients were included. Meta-analysis showed that compared the highest with the lowest category of SUA level, the summary risk ratios were 2.04 (95%CI 1.43–2.92, P < 0.001). The linear dose-response analysis revealed that the risk of DKD increased by 24% for each 1 mg/dl increase of SUA. The non-linear dose-response analysis also showed a significant relevance between SUA and the risk of DKD in patients with type 2 diabetes mellitus (P < 0.001).ConclusionsSerum uric acid is associated with an increased risk of diabetic kidney disease in patients with type 2 diabetes mellitus. Serum uric acid level could be a good indicator for predicting diabetic kidney disease in patients with type 2 diabetes mellitus.     

Predictors of hypoglycaemia in insulin-treated type 2 diabetes patients in primary care: A retrospective database analysis

AimsTo investigate the frequency and predictors (diabetes care and treatment, comorbidity) of documented hypoglycaemia in primary care patients with insulin-treated type 2 diabetes.MethodsData from 32,545 patients (mean age: 70 (SD 11) years, 50.3% males) from 1072 practices were retrospectively analyzed (Disease Analyzer database Germany: 09/2011–08/2012). Logistic regression (≥1 documented hypoglyemia) was used to adjust for confounders (age, sex, practice characteristics, diabetes treatment regimen).ResultsThe prevalence of patients (12 months) with at least one reported hypoglycaemia was 2.2% (95% CI: 2.0–2.4%). The adjusted odds of having hypoglycemia were increased for renal failure (OR; 95% CI: 1.26; 1.16–1.37), autonomic neuropathy (1.34; 1.20–1.49), and adrenocortical insufficiency (3.08; 1.35–7.05). Patients with mental disorders including dementia (1.49; 1.31–1.69), depression (1.24; 1.13–1.35), anxiety (1.18; 1.01–1.37), and affective disorders (1.80; 1.36–2.38) also showed an increased odds of having hypoglycemia. Location of the practice in an urban area was associated with a lower odds ratio (0.74; 0.68–0.80).ConclusionsBoth individual patient characteristics (e.g. comorbidity) and regional factors (practice location) have a substantial impact on hypoglycaemia in primary care patients with insulin therapy.     

Association of musculoskeletal pain with the achievement of treatment targets for type 2 diabetes among primary care patients

AimsTo assess the association of diagnosed musculoskeletal (MS) pain (low back, neck, shoulder, and knee pain; and the number of pain sites) with the achievement of targets for glycosylated haemoglobin A1c (HbA1c), low-density-lipoprotein cholesterol (LDL), and systolic blood pressure (SBP) among primary care patients with type 2 diabetes (T2D).MethodsThe cross-sectional study population consisted of 3478 patients with a registry-based T2D diagnosis and available registry-based data on MS pain diagnoses, covariates, and outcomes between 2016 and 2019. Logistic regression analysis was used to evaluate the study aims.ResultsOverall, 22% had at least one of the four types of MS pain, and 73%, 57%, and 51% achieved the treatment targets of HbA1c, LDL, and SBP, respectively. T2D patients with or without MS pain did not differ in their achievement of T2D treatment goals. Of pain locations, low back pain was associated with higher rates of achievement of the LDL target (OR 1.29, 95% CI 1.01–1.65), but the association was attenuated in the adjusted model.ConclusionsMS pain was relatively prevalent among primary care patients with T2D, but did not influence the achievement of T2D treatment goals.     

Higher HDL cholesterol levels are associated with a lower incidence of chronic kidney disease in patients with type 2 diabetes

Background and aimsType 2 diabetes is one of the most important risk factor for the development of chronic kidney disease (CKD). Recently, it has been shown that lower high-density lipoprotein cholesterol (HDL-C) levels predicted the development of microalbuminuria in type 2 diabetic individuals. We have prospectively assessed the effects of plasma HDL-C levels on the incidence of CKD in a large cohort of type 2 diabetic patients.Methods and resultsWe followed 1987 type 2 diabetic outpatients with normal or near-normal kidney function at baseline for 5 years for the occurrence of incident CKD defined as glomerular filtration rate ≤ 60 mL/min/1.73 m² (as estimated by the abbreviated Modified Diet and Renal Disease Study equation). Cox proportional hazards models were used to examine the independent relationship between plasma HDL-C levels and incident CKD. During a median follow-up of 5 years, 11.8% (n = 234) of participants developed incident CKD. In multivariate regression analysis, higher HDL-C levels were associated with a lower risk of incident CKD (multiple-adjusted hazard ratio 0.76; 95% coefficient intervals 0.61–0.96; p = 0.025) independently of age, gender, body mass index, hypertension, smoking history, diabetes duration, hemoglobin A1c, plasma triglycerides, LDL-cholesterol, presence of diabetic retinopathy, baseline albuminuria, and current use of medications (anti-hypertensive, anti-platelet, lipid-lowering and hypoglycemic drugs).ConclusionsHigher plasma levels of HDL-C are associated with a lower risk of incident CKD in a large cohort of type 2 diabetic adults independently of numerous confounding factors.