3 Contemporary Initiatives for Diabetes-Related Renal Health

As the leading cause of end stage renal disease (ESRD), diabetes requires significant attention from the renal community—to prevent and manage diabetes before it leads to ESRD, and also to manage diabetes as a comorbid condition of ESRD. The following three initiatives are dedicated to continuously improving these efforts.

1. Establishing Integrated Care Management Standards

To help reduce diabetes-related comorbid conditions and improve patient outcomes, clinicians must comprehensively combine all the features of medical management, including care programs, therapeutics and disease control. Diabetes-ESRD management programs, such as DaVita’s StepAhead Diabetes Management® program, play an important role in helping diabetic ESRD patients find a diabetes physician, receive annual dilated retinal exams (DREs), use an accurate glucometer and perform monthly foot checks. There is a need to build out more programs like StepAhead and to establish contemporary management standards for the diabetic ESRD population.

Establishing diabetes-ESRD management standards poses a challenge; there is controversy over optimal diabetes clinical tests and therapies for ESRD patients.  Between 2010 and 2013, comprehensive diabetes monitoring (administering at least one hemoglobin A1c (HbA1c) test, lipid test, and DRE annually) for ESRD patients declined by 37 percent. This may be partially due to increasing recognition that the HbA1c test does not accurately reflect blood glucose levels in patients with renal failure. To determine an optimal glucose test for ESRD patients, researchers have examined alternatives to HbA1c, such as glycated albumin, which is a shorter-term indicator of glucose control and yet may still predict risk of hospitalization and mortality. Research also needs to determine the following clinical standards:

• Whether glycemic variability poses a greater cardiovascular risk than an average blood glucose level
• The optimal glucose concentration in dialysate
• Safe non-insulin therapies
• How insulin doses and diet should be modified on dialysis versus non-dialysis days

2. Exploring New Therapies 

New therapies that could improve managing diabetes in ESRD patients are being explored, including the following:

• Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as teneligliptin and linagliptin, are newer treatments that may be able to safely and effectively manage diabetes in ESRD patients.
• Sodium-glucose co-transporter 2 (SGLT2) inhibitors may be effective as early treatments for diabetic chronic kidney disease (CKD) patients—they are ineffective for treating diabetic ESRD patients because they require glomerular filtration.
• Bariatric surgery is safe in some ESRD patients and shows beneficial effects on glucose metabolism.

 3. Developing Prevention Programs and Leveraging Advanced Technology

The Centers for Medicare & Medicaid Services (CMS) recognizes the importance of diabetes prevention. In March 2016, CMS certified the expansion of the Diabetes Prevention Program (DPP), which targets prediabetic patients to help prevent diabetes through activities such as exercise and dietary changes. The expansion, which CMS aims to begin implementing in January 2018, is designed to give more Medicare patients with prediabetes access to the DPP. The DPP model has achieved the following results:

• Participants reduced their body weight by approximately 5 percent
• Medicare saved approximately $2,650 per enrollee over 15 months

The DPP can be provided digitally through the Virtual Lifestyle Management™ (VLM) program developed by Canary Health. This program, created to help patients manage their prediabetes, leverages advanced technology as an effective alternative to in-person delivery. Digital delivery could potentially reduce per-person costs and administrative burden, according to Neal Kaufman, MD, MPH, founder and CMO of Canary Health. The VLM program can help lower the rate of progression to diabetes and other comorbidities, thereby possibly lowering the likelihood of patients developing diabetes-related renal disease. Canary Health also developed Stanford’s Better Choices Better Health™, a peer-to-peer self-management digital program for patients who have diabetes and other chronic conditions. The program has helped improve participants’ HbA1c results, hypoglycemia, medication adherence and depression.

Practices that use electronic health records (EHRs) can also achieve better results in diabetes care. In 2011, CMS established the EHR Incentive Programs to encourage increased EHR use. As of 2015, 95 percent of eligible hospitals used certified health IT through the EHR Incentive Programs. Only 56 percent of office-based physicians, 16 percent of nurse practitioners and 2 percent of physician assistants used them. Increasing EHR usage in practices may have a greater impact on managing diabetic CKD patients than diabetic ESRD patients.

As the diabetic population continues to grow, these initiatives will play a vital role in preventing diabetes from escalating to ESRD and improving clinical outcomes for those who have diabetes and ESRD.

Note: The content within this article has been republished with permission from Nephrology News & Issues.