Management of Diabetes 100 Years After the Discovery of Insulin: Nuances for the Kidney

Abstract

because before this, individuals with diabetes could only live for a few years, even following strict diets. Consequently, insulin treatment lengthened the lives of patients with diabetes, and with greater longevity, diabetic kidney disease was recognized more widely. Diabetic kidney disease is the leading cause of kidney failure in the United States and worldwide, accounting for 45% of cases in the United States. Approximately 30% of patients with type 1 diabetes mellitus (T1DM) and w40% of patients with type 2 diabetes mellitus (T2DM) develop diabetic kidney disease. The increasing prevalence of diabetic kidney disease aligns with the growing prevalence of diabetes worldwide. Currently, w10% of the world’s population (463 million people) carries a diagnosis of diabetes and the prevalence of diabetes is projected to increase to >11%, with 700 million people being diagnosed with diabetes by 2045. Traditionally, interventions that have proven useful in preventing or slowing the progression of diabetic kidney disease include strict blood pressure control, cessation of smoking, control of hyperlipidemia, restriction of protein intake, and of course, strict glycemic control. Critically, the past decade has seen tremendous advances in medications for reducing diabetic kidney disease risk and progression. In this issue of Kidney Medicine, Zhao et al evaluate diabetes medication use among US Medicare beneficiaries between 2007 and 2016. They reported that insulin and metformin were the most often used hypoglycemic agents in Medicare patients with chronic kidney disease (CKD), an unsurprising but important finding. The authors also noted that newer glucose-lowering medication use, although low, increased significantly during the course of the study, including dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, and sodium-glucose cotransporter 2 (SGLT2) inhibitors. Two landmark trials conducted in patients with earlystage T1DM and T2DM showed that intensive blood glucose control early in the course of disease demonstrates a long-lasting favorable effect on the risk for developing diabetic kidney disease. Furthermore, in the ADVANCEON study, tight glycemic control with an average glycated hemoglobin level of 7.2% helped reduce the onset of