Diabetic Kidney Disease in Kenya: How to Keep this dreaded complication at bay

Diabetes mellitus has emerged as a major public health challenge in Kenya, with significant implications for the country’s kidney health. As such, diabetic kidney disease has become one of the leading causes of chronic kidney disease (CKD) in the country.

Table of Contents

• The Burden of Diabetes and Kidney Disease in Kenya
• Diabetic Nephropathy
• Risk Factors and Pathogenesis of Diabetic Kidney Disease
  • Metabolic Factors
  • Hemodynamic Factors
  • Growth Factors
  • Proinflammatory and Profibrotic Factors
• Screening and Early Detection of Diabetic Kidney Disease
• Screening and Diagnosis of Diabetic Kidney Disease
  • Urinary Albumin Excretion
  • Estimated Glomerular Filtration Rate (eGFR)
• Diagnosis of diabetic kidney disease
• Screening Guidelines
• Emerging Screening Methods
• Management of Diabetic Kidney Disease
  • Glycemic Control
  • Blood Pressure Management
  • Pharmacological Interventions
• Challenges and Opportunities in Addressing Diabetic Kidney Disease in Kenya
• Way Forward: Getting ahead of Diabetic Nephropathy
  • Disclaimer
• References
• Sharing is Caring
• Author

The Burden of Diabetes and Kidney Disease in Kenya

According to the Kenya Renal Association, the number of hemodialysis units in the country has grown from just 10 in 2006 to 102 by March 2018, with the number of patients on chronic hemodialysis increasing from 300 to 2,400 during the same period.[1] This dramatic rise underscores the growing burden of kidney disease, much of which is driven by the diabetes epidemic.

Diabetic Nephropathy

Diabetic nephropathy, also known as diabetic kidney disease, is a serious complication of diabetes that occurs when high blood glucose levels damage the kidneys over time. It is characterized by the following:

• Proteinuria (protein leaking into the urine) due to damage to the glomeruli, which are the kidney’s filtering units
• Rising blood pressure and hypertension
• Progressive loss of kidney function, leading to a decline in the estimated glomerular filtration rate (eGFR)

A study conducted at a regional referral hospital in central Kenya found that 39% of patients with type 2 diabetes had CKD in stages 3-5, indicating a substantial burden of unrecognized kidney disease among this population.[2] Another study at the Kenyatta National Hospital, the country’s largest tertiary facility, reported that 27% of medical inpatients had CKD, with diabetes and hypertension being the leading risk factors.[3]

Risk Factors and Pathogenesis of Diabetic Kidney Disease

The pathogenesis of diabetic nephropathy (DN) is complex and multifactorial, involving an interplay of metabolic, hemodynamic, growth, and proinflammatory/profibrotic factors. The key mechanisms driving the development and progression of DN include:

Metabolic Factors

• Hyperglycemia leads to the production of advanced glycation end-products (AGEs) through non-enzymatic glycation of tissues
• Increased flux through the polyol pathway and hexosamine pathway also contribute to kidney injury
• Oxidative stress due to an imbalance between reactive oxygen species (ROS) generation and antioxidant defenses is central to the pathogenesis of DN

Hemodynamic Factors

• Hyperfiltration and glomerular hypertension, mediated by vasoactive factors like nitric oxide, prostaglandins, and angiotensin II, cause glomerular injury
• Vascular disease of the afferent arteriole leads to permanent alterations in renal autoregulation favoring glomerular hypertension

Growth Factors

• Vascular endothelial growth factor (VEGF) is activated early, leading to vascular expansion and hyaline arteriosclerosis
• Angiopoietins can also cause vascular proliferation and have been implicated in the pathogenesis of DN

Proinflammatory and Profibrotic Factors

• Inflammation and fibrosis are important causes of DN, mediated by cytokines, chemokines, and profibrotic factors
• Infiltration of monocytes and macrophages leads to inflammation and further kidney injury

The pathogenetic factors produce lesions in various kidney compartments, including glomeruli, tubuli, interstitium, and vasculature. This leads to a complex series of structural changes, such as glomerular basement membrane thickening, mesangial expansion, nodular glomerulosclerosis, global glomerulosclerosis, glomerulomegaly, vascular lesions, interstitial fibrosis and tubular atrophy (IFTA), and ultimately, end-stage renal disease (ESRD).

Screening and Early Detection of Diabetic Kidney Disease

Early detection of DKD is crucial, as it allows for timely intervention to slow disease progression and prevent the development of end-stage renal disease (ESRD). The American Diabetes Association recommends annual screening for albuminuria and estimation of glomerular filtration rate (eGFR) in all individuals with diabetes, starting 5 years after the onset of type 1 diabetes and at the time of diagnosis for type 2 diabetes.

In Kenya, community-based screening initiatives have been undertaken to identify individuals with undiagnosed CKD, including those with diabetes. A study that analyzed data from such screening efforts between 2011 and 2019 found that 5,138 individuals were screened, with a significant proportion having hypertension, diabetes, and other risk factors for kidney disease.[1]

Screening and Diagnosis of Diabetic Kidney Disease

Early detection of diabetic kidney disease (DKD) is crucial, as it allows for timely intervention to slow disease progression and prevent the development of end-stage renal disease (ESRD). The screening and diagnosis of DKD involves the following key modalities:

Urinary Albumin Excretion

• Microalbuminuria, defined as elevated levels of albumin in the urine, is the earliest detectable marker of DKD[1][2].
• The American Diabetes Association recommends annual screening of urinary albumin (spot urine albumin/creatinine ratio) in patients who have had type 1 diabetes for at least five years, in all patients with type 2 diabetes beginning at the time of diagnosis, and in all patients who have comorbid hypertension[1][3].
• Albumin has become the recommended protein screening modality because of its manifestation in the majority of chronic kidney disease (CKD) cases, its ease of measurement, and its ability to predict future renal function decline[2].

Estimated Glomerular Filtration Rate (eGFR)

• The eGFR should be calculated from serum creatinine using the Chronic Kidney Disease Epidemiology Collaboration equation[1].
• A decline in eGFR is a hallmark of DKD progression, and screening for eGFR is recommended along with urinary albumin testing[1][2].

Diagnosis of diabetic kidney disease

• Diagnosis is made clinically when a patient has evidence of kidney disease and no other primary etiology[1].
• Early referral to nephrology (at CKD stage 3 or 4) may help improve DKD outcomes and should be considered[1].

Screening Guidelines

• The National Kidney Foundation (NKF) and the American Diabetes Association (ADA) recommend screening all adults with type 2 diabetes for increased urine albumin excretion at the time of diagnosis and annually thereafter[3].
• Screening for kidney disease in adults with diabetes is generally aimed at conditions with a substantial public health impact and which benefit from early interventions[3].

Emerging Screening Methods

• Emerging epidemiologic data suggest that population patterns of CKD among adults with type 2 diabetes are not as uniform as those noted among adults with type 1 diabetes[3].
• Focusing solely on urine albumin excretion to screen for CKD may miss a substantial number of cases in adults with type 2 diabetes, a more heterogeneous group of patients who are generally older and have more comorbid conditions at diagnosis compared with adults with type 1 diabetes[3].
• Other etiologies for CKD, which are not associated with increased urine albumin excretion, may be operable at the time of diagnosis of type 2 diabetes and over the course of their disease, such as renal vascular disease and cholesterol emboli[3].

Management of Diabetic Kidney Disease

The management of DKD involves a multifaceted approach, including glycemic control, blood pressure management, and the use of specific pharmacological interventions.

Glycemic Control

Tight glycemic control, as measured by hemoglobin A1c (HbA1c) levels, has been shown to delay the onset and slow the progression of DKD. The American Diabetes Association recommends an HbA1c target of less than 7% for most adults with diabetes, with more or less stringent goals based on individual patient factors.

Blood Pressure Management

Controlling blood pressure is crucial in DKD, as it helps to reduce intraglomerular pressure and proteinuria. The recommended blood pressure target for individuals with diabetes and CKD is less than 130/80 mmHg. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are the preferred antihypertensive agents, as they have been shown to provide additional renoprotective effects.

Pharmacological Interventions

In addition to glycemic and blood pressure control, the use of specific medications, such as ACE inhibitors, ARBs, and sodium-glucose cotransporter-2 (SGLT2) inhibitors, has been shown to slow the progression of DKD. These drugs can reduce proteinuria, improve eGFR, and lower the risk of ESRD.[6,7]

Challenges and Opportunities in Addressing Diabetic Kidney Disease in Kenya

The management of DKD in Kenya faces several challenges, including limited access to specialized kidney care, financial constraints, and low awareness among both healthcare providers and the general population.

To address these challenges, a multifaceted approach is needed, involving:

1. Strengthening primary care and community-based screening: Integrating DKD screening and management into primary care settings and conducting regular community-based screening campaigns can help identify individuals with undiagnosed kidney disease and facilitate early intervention.
2. Improving access to specialized kidney care: Increasing the number of nephrologists, dialysis units, and kidney transplant facilities can improve access to specialized care for individuals with advanced DKD.
3. Enhancing public awareness and education: Launching public awareness campaigns to educate the population about the link between diabetes and kidney disease, as well as the importance of early detection and management, can empower individuals to take proactive steps in their health.
4. Promoting multidisciplinary care: Encouraging collaboration between endocrinologists, nephrologists, primary care providers, and other healthcare professionals can ensure a comprehensive and coordinated approach to the management of DKD.
5. Strengthening the healthcare system: Investing in the healthcare infrastructure, including the availability of essential medications and diagnostic tools, can improve the overall management of DKD in Kenya.

By addressing these challenges and implementing a comprehensive strategy, Kenya can make significant strides in reducing the burden of diabetic kidney disease and improving the overall health and well-being of its population.

Way Forward: Getting ahead of Diabetic Nephropathy

Diabetes has emerged as a leading cause of chronic kidney disease in Kenya, with a significant and growing impact on the country’s healthcare system. Addressing this public health challenge requires a multifaceted approach that focuses on early detection, effective management, and a strengthened healthcare infrastructure. By prioritizing the prevention and treatment of diabetic kidney disease, Kenya can work towards improving the lives of those affected and reducing the burden of this devastating complication of diabetes.

Disclaimer

The information provided on this medical blog is for general informational purposes only and should not be considered as a substitute for professional medical advice. Always consult with a qualified healthcare provider before making any healthcare decisions or taking any actions based on the information provided on this blog. The authors and publishers of this blog are not liable for any errors or omissions in the content or for any actions taken based on the information provided.

References

1. Kabinga, S. K., McLigeyo, S. O., Twahir, A., Ngigi, J. N., Wangombe, N. N., Nyarera, D. K., … & Moturi, G. M. (2020). Community Screening for Diabetes, Hypertension, Nutrition, and Kidney Disease Among Kenyans. Kidney International Reports, 5(3), 341-349.
2. Otieno, F. C. F., Ogola, E. N., Kimando, M. W., & Mutai, K. (2020). The burden of unrecognised chronic kidney disease in patients with type 2 diabetes at a county hospital clinic in Kenya: implications to care and need for screening. BMC Nephrology, 21(1), 73.
3. Juma, A. R., Ogola, E. N., Otieno, C. F., & Ndege, R. (2018). Prevalence and factors associated with chronic kidney disease among medical inpatients at the Kenyatta National Hospital, Kenya, 2018: a cross-sectional study. The Pan African Medical Journal, 33, 321.
4. Alicic, R. Z., Rooney, M. T., & Tuttle, K. R. (2017). Diabetic kidney disease: challenges, progress, and possibilities. Clinical Journal of the American Society of Nephrology, 12(12), 2032-2045.
5. Afkarian, M., Zelnick, L. R., Hall, Y. N., Heagerty, P. J., Tuttle, K., Weiss, N. S., & de Boer, I. H. (2016). Clinical manifestations of kidney disease among US adults with diabetes, 1988-2014. Jama, 316(6), 602-610.
6. American Diabetes Association. (2022). 11. Chronic Kidney Disease and Risk Management: Standards of Medical Care in Diabetes—2022. Diabetes Care, 45(Supplement_1), S175-S184.
7. Heerspink, H. J., Stefánsson, B. V., Correa-Rotter, R., Chertow, G. M., Greene, T., Hou, F. F., … & Wheeler, D. C. (2020). Dapagliflozin in patients with chronic kidney disease. New England Journal of Medicine, 383(15), 1436-1446.