Barriers for preventing CKD in patients with diabetes

So what are the barriers for preventing CKD? Of course, we should have the diagnosis before we can treat. It's very easy. We always tell to our young doctors: establish the diagnosis first. And the diagnosis can be simply done by a test. And we know this we, nephrologists, we do it by serum creatinine and give the creatinine in an equation and then we have albuminuria for kidney damage. So we test kidney function and damage. And this is the message we, nephrologists, transfer outside. We know this, but it's a simple message we give to our other colleagues out there. And this is eGFR and urinary albumin creatinine ratio, standardized tests done in a laboratory.

Here is my transparency declaration. And you see companies which are active on the field of SGLT2 inhibitors and developing anti-diabetic medication, organ protective medication and doing clinical trials. I'm working in clinical trials, so far.

And this cartoon comes from the year 2003. But you nephrologists, you can easily detect how we are thinking about CKD. Here we see for example, a type 1 diabetic at the age of 25 and he is progressing. And then people out there progressing at a different rate. It's 5 ml, a rapid progressor or it's only 3 ml and we follow these patients until they reach end-stage kidney disease and this is our world and we want with an intervention to change this slope. However, when we come often into the game, it's for some perception too late or the question is: what can we do when coming in below a GFR of 30 with retarding the progression? So I drew up this slide, which is really known to us, but I think when we give this slide to primary care prevention, it is an eye-opener, it's so easy. What the nephrologists want to do, they want to prevent progression, changing the slope, and we have to work together with primary care because we don't see them in that eGFR of 60/70. So just take this cartoon. Change the x-axis for age, move it to the left because you see a type 2 diabetic at the age of 65. You may see them at a GFR of 50. So you start with your slope at GFR of 50 and 65. Yeah, just a different area.

Next, this is our world, KDIGO since more than 10 years, the heat map. Indicating glomerular filtration rate at the left, and albuminuria on the top. This is also easy to give it to other doctors. In blue, are those perfectly healthy, in yellow, and then red those who are on the slope and endangered including albuminuria UACR. On the right hand side is the old term macroalbuminuria with a UACR above 300. Those people are mainly on the slope towards and important for us to discuss with general practitioners also, the G1, 2 (stage 1 and 2) and A2 and A3 categories. The upper part is pretty normal kidney function. But if you have high albuminuria, it is kidney disease. And this is invisible, when you do only GFR, and it doesn't cause any pain. It needs a test of albuminuria. That's a message.

And actually, the cardiologists, our friends, and colleagues published in the European Heart Journal last August, the primary assessment of cardiovascular disease in primary prevention. They adopted the heat map. Cardiologists acknowledged the KDIGO 4 risk classes and they just said in their guidelines: the CKD severity is low CKD, moderate CKD, severe CKD and those with moderate CKD are at high cardiovascular disease risk and those with severe CKD are very high. This fits in their language, in their guidelines. And according to my perception, it helps us.

And they came up with an ABCDE scheme. So B is blood pressure, cholesterol and diabetes D, but A is albuminuria. And E is eGFR. And albuminuria and eGFR are independent predictors of progression and, not only CKD, but also cardiovascular disease and it is discussed whether this should be done on a population level. But the cost-benefit ratio is not yet positive, when you do it on a population level. So we do it in risk groups and we may hear more about this.