Chronic Renal Disease

ADA: Linagliptin Works in Diabetic Kidney Disease

Program Overview
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Learning Objectives
Upon successful completion of this educational program, the reader should be able to:
1. Discuss the results of this study
2. Review the relevance and significance of the study in the broader context of clinical care

Disclosures
Robert Jasmer, MD , and Ed Susman , have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

The staff of Projects In Knowledge , Inc. and the staff of MedPage Today have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

Accreditation
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Projects In Knowledge , Inc. designates this enduring material for a maximum, of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.

The Patient with Chronic Renal Disease

Chronic renal failure (CRF) is present when the glomerular filtration rate (GFR) is permanently decreased in association with the loss of functional nephron population . It is characterized by continuing attrition of nephrons and variable but usually unrelenting progression toward end-stage renal disease (ESRD). Although patients with CRF have an elevated serum creatinine (Scr), other uremic and metabolic derangements, such as hyperkalemia and acidosis, may be absent. In 1996, the United States Renal Data System (USRDS) reported an ESRD incidence of 268 per 1 million people per year, for a total prevalence of 283,000 patients. The prevalence of ESRD has increased by approximately 8% per year over the last decade, due to the combined effects of a rising incidence of renal disease in the 60-to-75-year age group and mortality rates that have remained nearly constant. More than 300,000 people will be treated for ESRD by the year 2000. CRF is costly: For dialysis patients, Medicare spends approximately $45,000 per patient per year, for a total of $10 billion annually. The cost of caring for non-ESRD patients with chronic renal disease is unknown. I. Epidemiology and etiology. Although relatively complete and accurate statistics on ESRD are available, limited epidemiologic data exists for CRF in general. The causes of CRF have been assumed to correspond proportionately to the causes of ESRD, though this was not proved until the 1990s. A contemporary, large-scale survey conducted in the U.S. population suggests that more than 3 million people have an Scr higher than 1.7 mg per dL. As detailed in section IV.A, however, Scr gives an imprecise estimate of renal function and may vary independently according to race, dietary intake, age, gender, and muscle mass. Table 10-1 lists the most prevalent causes of ESRD. The majority of patients have diabetes mellitus, hypertension, or both. Studies suggest a synergism between hyperglycemia and elevated blood pressure in destroying nephrons. As a group, glomerular diseases are the third most common cause of ESRD; they include idiopathic disorders, such as focal and segmental glomerulosclerosis (FSGS) and membranous nephritis, and secondary nephritis due to systemic illness such as systemic lupus erythematosus and Wegener’s granulomatosis. Interstitial disease, polycystic kidney disease, and obstructive uropathy each account for 3% to 5% of new cases. In contrast to hypertension and diabetes, which can cause CRF at any age, most other causes have a predilection for specific age groups. Idiopathic FSGS, lupus nephritis, and congenital anomalies of the urinary tract commonly lead to CRF before the age of 40. Polycystic kidney disease, idiopathic membranous glomerulonephritis, membranoproliferative glomerulonephritis (MPGN), and scleroderma lead to CRF and ESRD in the 40-to-55-year age group. In patients older than 55 years, cholesterol-emboli disease (blue-toe syndrome), analgesic nephropathy, multiple myeloma (including light-chain disease), ischemic nephropathy, and Wegener’s granulomatosis are some of the common causes. The latest statistics from the USRDS indicate that diabetes, glomerulonephritis, secondary glomerulonephritis, vasculitis, and congenital diseases are overrepresented in the 20-to-64-year age group. Hypertension and renal neoplasms are more common in patients older than 64 years. Interstitial nephritis is seen more frequently in the youngest and oldest patients. Primary glomerulonephritis, hypertension, and neoplasms are more frequent in males, and secondary glomerulonephritis and diabetes are overrepresented in females. Primary renal diseases are confined to the kidneys and usually present with CRF or nephrotic syndrome without a history of systemic illness. Nonglomerular diseases such as obstructive uropathy, primary interstitial nephritis, and ischemic nephropathy are often identified during the workup for newly discovered hypertension or asymptomatic hematuria. Patients presenting with proteinuria or nephrotic syndrome but without evidence of infection, collagen-vascular disease, or malignancy are likely to have idiopathic glomerulonephritis. Because patients with primary renal disorders are either asymptomatic or have the nonspecific symptoms of chronic renal disease, renal biopsy is often necessary for diagnosis.

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