Optimizing care for Canadians with diabetic nephropathy in 2015

Diabetic chronic kidney disease (CKD) is the cause of kidney failure in approximately 35% of Canadian patients requiring dialysis. Traditionally, only a minority of patients with type 2 diabetes and CKD progress to kidney failure because they die of a cardiovascular event first. However, with contemporary therapies for diabetes and cardiovascular disease, this may no longer be true. The classic description of diabetic CKD is the development of albuminuria followed by progressive kidney dysfunction in a patient with longstanding diabetes. Many exciting candidate agents are under study to halt the progression of diabetic CKD; current therapies center on optimizing glycemic control, renin angiotensin system inhibition, blood pressure control and lipid management. Lifestyle modifications, such as salt and protein restriction as well as smoking cessation, may also be of benefit. Unfortunately, these accepted therapies do not entirely halt the progression of diabetic CKD. Also unfortunately, the presence of CKD in general is under-recognized by primary care providers, which can lead to late referral, missed opportunities for preventive care and inadvertent administration of potentially harmful interventions. Not all patients require referral to nephrology for diagnosis and management, but modern risk-prediction algorithms, such as the kidney failure risk equation, may help to guide referral appropriateness and dialysis modality planning in subspecialty nephrology multidisciplinary care clinics.