As the leading cause of end-stage renal disease (ESRD),1 diabetes requires significant attention from the renal community to effectively prevent and manage it before it leads to ESRD, and also to manage diabetes as a comorbid condition of ESRD. The following three initiatives are program developed at DaVita Kidney Care and dedicated to continuously improving these efforts.
- Establishing integrated care management standards
Comprehensively combining all the features of medical management—including care programs, therapeutics, and disease control—to support diabetic ESRD patients is vital to helping reduce diabetes-related comorbid conditions and improve patient outcomes. Programs such as Step Ahead Diabetes Management play an important role in helping diabetic ESRD patients find a 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.2 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%.3 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, studies 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.4 Research also needs to determine the following clinical standards:5
- 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.
- 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 teneligliptin6 and linagliptin,7 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.8
Bariatric surgery is safe in some ESRD patients and shows beneficial effects on glucose metabolism.9
- Developing prevention programs and leveraging advanced technology
The Centers for Medicare & Medicaid Services (CMS) recognizes the importance of diabetes prevention. This past March, the agency 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.10 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.11
Participants reduced their body weight by approximately 5%.
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.12
Practices that use electronic health records (EHRs) can also achieve better results in diabetes care.13 In 2011, CMS established the EHR Incentive Programs to encourage increased EHR use. As of 2015, 95% of eligible hospitals used certified health IT through the EHR Incentive Programs. Only 56% of office-based physicians, 16% of nurse practitioners, and 2% of physician assistants used them.14 Increasing EHR usage in practices may have a greater impact on managing diabetic CKD patients than diabetic ESRD patients.15
These initiatives will play a vital role in preventing diabetes from escalating to ESRD, as well as improving clinical outcomes for those who have diabetes and ESRD.15
- The Centers for Disease Control and Prevention. National Chronic Kidney Disease Fact Sheet, 2014.
- S. Renal Data System Annual Data Report, 2015, chart 3
- Freedman BI, Andries L, Shihabi ZK, et al. Glycated albumin and risk of death and hospitalizations in diabetic dialysis patients. Clin J Am Soc Nephrol. 2011; 6(7):1635-43. doi: 10.2215/CJN.11491210.
- Bilous RW. Glycemic control and mortality in diabetic patients undergoing hemodialysis: Much more to learn. Am J Kidney Dis. 2014; 63(1):10-12].
- Otsuki H, Kosaka T, Nakamura K, et al. Safety and efficacy of teneligliptin: a novel DPP-4 inhibitor for hemodialysis patients with type 2 diabetes. Int Urol Nephrol. 201446(2):427-32. doi: 10.1007/s11255-013-0552-6.
- Cooper MD, Perkovic V, McGill JB, et al. Kidney disease end points in a pooled analysis of individual patient–level data from a large clinical trials program of the dipeptidyl peptidase 4 inhibitor linagliptin in Type 2 diabetes. Am J Kidney Dis. 2015; 66(3):441-449.
- Scheen AJ. Pharmacokinetics, pharmacodynamics and clinical use of SGLT2 inhibitors in patients with Type 2 diabetes mellitus and chronic kidney disease. Clin Pharmacokinet. 2015; 54(7):691-708. doi: 10.1007/s40262-015-0264-4.
- Modanlou KA, Muthyala U, Xiao H et al. Bariatric surgery among kidney transplant candidates and recipients: Analysis of the United States Renal Data System and literature review. 2009; 87(8): 1167–1173.doi:10.1097/TP.0b013e31819e3f14.
- Centers for Medicare & Medicaid Services. Medicare diabetes prevention program expansion. July 7, 2016. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-07.html
- S. Department of Health & Human Services. Independent experts confirm that diabetes prevention model supported by the Affordable Care Act saves money and improves health. March 23, 2016. http://www.hhs.gov/about/news/2016/03/23/independent-experts-confirm-diabetes-prevention-model-supported-affordable-care-act-saves-money.html?_sm_byp=iVVJPDLrVsLrRNq3
- Lorig K, Ritter PL, Turner RM, et. al. Benefits of diabetes self-management for health plan members: A 6-month translation study. J Med Internet Res. 2016; 18(6): e164.
- Cebul RD, Love TE, Jain AK, Hebert CJ. Electronic health records and quality of diabetes care. N Engl J Med. 2011; 365:825-833.
- The Office of the National Coordinator for Health Information Technology. Quick Stats. http://dashboard.healthit.gov/quickstats/quickstats.php
- Drawz PE, Archdeacon P, McDonald CJ, et al. CKD as a model for improving chronic disease care through electronic health records. Clin J Am Soc Nephrol. 2015; 10(8):1488-99. doi: 10.2215/CJN.00940115.