Diagnosis and treatment of chronic kidney diseases and Type 2 diabetes mellitus: a paradigm shift for enhancing cardiovascular prognosis

Abstract

For years, chronic kidney disease has been a global and growing health problem that not only significantly impairs the quality of life of patients but is also associated with high mortality and morbidity. A significant concern is the strong link between chronic kidney diseases, Type 2 diabetes mellitus, and cardiovascular disease, with cardiovascular disease being the leading cause of death among patients suffering from chronic kidney disease [1]. These comorbidities exacerbate each other, significantly worsening the overall health of the patients. The high prevalence underscores the urgent need for new, integrated strategies for prevention and treatment to improve the prognosis of affected patients [2].

The central problem in the treatment of chronic kidney disease is that it often begins asymptomatically. The disease often goes unnoticed in its early stages, allowing valuable time to pass during which therapeutic intervention could be particularly effective. Patients are often not diagnosed until the disease is advanced, at which point therapeutic options are less effective. To close this diagnostic gap, the guidelines recommend regular monitoring of high-risk individuals, especially those with diabetes mellitus or hypertension. Two diagnostic parameters are essential in this context: the estimated glomerular filtration rate (eGFR) and the urinary albumin-to-creatinine ratio (UACR). Although eGFR tests are routinely performed, UACR tests remain underrepresented. This discrepancy leads to an underdiagnosis of chronic renal failure, as a result of which many patients are not identified and treated in time. The measurement of albuminuria is not only diagnostically relevant but also provides a basis for targeted therapeutic decisions. The increased implementation of diagnostic measures on a broader basis could help to significantly reduce the global burden of chronic renal failure and its complications in the long term.

In addition to the diagnostic aspects, therapeutic approaches also play a crucial role. They are essential to slow the progression of the disease and improve the quality of life of patients. However, the therapeutic focus for chronic kidney disease and Type 2 diabetes was limited to blood glucose and blood pressure control in the past, often without addressing the interconnected pathophysiological causes of cardiovascular complications. After many years of a lack of effective therapeutic options for the treatment of the early stages of chronic renal failure, there has been a remarkable development of new treatment options in recent years. These innovative approaches not only open up novel perspectives for slowing the progression of the disease but also for improving the quality of life and prognosis of affected patients.

First and foremost in this context are the established renin-angiotensin system inhibitors, which lower intraglomerular pressure and thus slow the progression of kidney disease. These substances have been shown to be effective in maintaining renal function and reducing the risk of cardiovascular events in patients with chronic kidney disease [3]. Their widespread use underscores their importance as a fundamental component in the treatment of chronic renal failure.

In addition, sodium-glucose cotransporter-2 inhibitors are of particular relevance. Initially developed for glycemic control in patients with diabetes mellitus, these substances have demonstrated remarkable nephro- and cardioprotective effects in clinical studies. These properties open up promising therapeutic approaches, particularly for patients with chronic kidney disease and heart failure and underscore their potential beyond glycemic control [4]. Glucagon-like peptide-1 receptor agonists have been developed and successfully established, in particular, for blood sugar control. In addition to their effect on blood sugar, these substances also have significant cardiovascular benefits. These include a reduction in cardiovascular events, which further underscores their importance in the treatment of patients with diabetes and cardiovascular diseases [5]. These bidirectional effects open up new therapeutic perspectives for chronic renal failure patients at increased risk for cardiovascular complications. In this context, nonsteroidal mineralocorticoid receptor antagonists should not be neglected. This substance class reduces the expression of the renal outer medullary potassium channel and the epithelial sodium channel in the kidney, which leads to reduced reabsorption of sodium ions and increased diuresis [6]. In this way, they help to lower blood pressure and can potentially counteract hypertension [7].

In the article entitled “Treatment strategies to reduce cardiovascular risk in persons with chronic kidney disease and type 2 diabetes” in this issue of the Journal of Internal Medicine [8], Zannad et al. emphasize the importance of early and detailed diagnostics, and the timely initiation of guideline-based therapies is essential to slow the progression of chronic kidney disease and minimize the resulting cardiovascular risk. In light of the new therapeutic options, the authors emphasize that, in addition to early diagnosis, the effective combination of these innovative treatment approaches is of particular importance for patients. The article clearly stated that only through the targeted integration of these therapeutic options can optimal treatment efficiency be achieved and the prognosis for patients significantly improved [8]. Following the evidence-based approach of the authors, new clinical studies are now needed to validate and further develop these approaches. These studies should evaluate the long-term efficacy and safety of these approaches. The optimal application of these treatments in clinical practice can be ensured only through such comprehensive clinical investigations.

This article in the Journal of Internal Medicine [8] highlights the fact that we are at a turning point in the treatment of chronic kidney disease. The tools for effective diagnosis and therapy are available to treat chronic kidney disease—now it is important that we use them consistently. This requires not only a change in clinical practice but also the establishment of an interdisciplinary approach that brings together nephrologists, diabetologists, cardiologists, and primary care physicians. Combating chronic kidney disease and its comorbidities is one of the greatest challenges in modern medicine. In addition, the diagnostic and therapeutic approaches described in the work open up new possibilities for personalized therapy that can be tailored to the individual needs of patients.

Joachim Jankowski: Conceptualization; writing—original draft; writing—review and editing; funding acquisition.

JJ is co-founder and co-owner of the “Aachen-Maastricht Institute for Cardiorenal Disease” (AMICARE).