Improving outcomes in diabetes and chronic kidney disease: the basis for Canadian guidelines

The prevalence of diabetes is on the rise in Canada, and there has been a corresponding increase in the rate of micro- and macrovascular complications. Among the worst of these is chronic kidney disease (CKD). It may be diagnosed either through the detection of persistent albuminuria or an estimated glomerular filtration rate that is persistently less than 60 mL/min/1.73 m2. Patients with diabetes and CKD have a lower quality of life and higher health care costs, and face the prospect of end-stage renal disease requiring dialysis. More importantly, this group has an extremely elevated cardiovascular risk and correspondingly reduced survival. Research over several decades has led to two important conclusions. First, progressive worsening of kidney disease is not inevitable in people with diabetes; it can be slowed or even stopped. Second, the elevated cardiovascular risk in this population can be significantly reduced through an aggressive approach to cardiovascular risk factor reduction. These conclusions have prompted Canadian guideline groups, such as the Canadian Diabetes Association and the Canadian Hypertension Education Program, to release clinical practice guidelines that address the management of people with diabetes and CKD. In the present article, the studies that have influenced these Canadian guidelines are examined, and areas in which further research is still required are identified.