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Cardio Diabetes Medicine 2017 149

DKD is Coronary Equivalent

(Evidence and Remedy)

Dr.T. Dhinakaran, M.D., MNAMS., D.M.,(Neph)

Director and Chief Nephrologist, Madurai Kidney Centre & Transplantation Research Institute,
6/6 B-2 Sivagangai Road, Madurai.

INTRODUCTION vated plasma creatinine concentration or RRT had an
Cardiovascular disease (CVD) is the leading cause of annual death rate of 19.2% (95% confidence interval,
death in people with diabetes, especially accounting CI, 14.0–24.4%). There was a trend towards an increas-
for approximately 80% of mortality in type 2 diabetic ing risk of cardiovascular death associated with in-
(T2DM) patients. The Framingham Heart Study has creasing severity of nephropathy (P < 0.0001), with
1,2
shown a 2–10 fold excess risk of CAD, stroke, heart an annual death rate of 0.7% for subjects with no
failure, and CVD death among subjects with diabetes nephropathy, a rate of 2.0% for those with microal-
compared with non-diabetic subjects. buminuria, a rate of 3.5% for those with macroalbu-
3
minuria, and a rate of 12.1% for those with an elevated
The mortality and cumulative incidence of CVD are plasma creatinine concentration or RRT.
much higher in T1DM patients with DN than in those
without nephropathy. The relative risk for T1DM with The mechanism through which the relationship be-
4
DN compared with those without DN was 10.3 fold tween albuminuria and GFR mediate cardiovascular
higher for coronary heart disease, 10.9 fold higher for and renal outcomes is an area of great interest. It
stroke, and 10 fold higher for any CVD, with similar has been suggested that albuminuria and reduced
4
rates in men and women. GFR may simply represent the renal manifestations
6,7
of systemic endothelial dysfunction and systemic
8,9
PROTEINURIA : GLOMERULAR atherosclerosis, respectively. Indeed, it is likely that
albuminuria and reduced GFR may be markers of dif-
FILTERATION RATE AND CARDIAC RISK ferent pathologic processes.
The irony is that cardiac risk overtakes the renal
risk at all stages of DN. As renal involvement pro- HYPERGLYCEMIA
gresses, the CV risk also progresses, but at a faster The role of glycemic control in preventing the mac-
pace. This intriguing and unexpected deviation in the rovascular complications of diabetes is somewhat
5
course of renocardiac race is explicitly brought about controversial, although epidemiologic studies have
by an analysis of United Kingdom Diabetes Prospec- shown an association between hyperglycemia and
tive Study (UKPDS) data by Adler et al.
macrovascular complications. 10-12 For example, in
The progression to microalbuminuria occurred at a the UKPDS observational study, each 1% reduction
rate of 2.0% per year, the progression from microal- in HbA1c was associated with 18% fewer MIs and
buminuria to macroalbuminuria occurred at a rate of 21% fewer diabetes related deaths. But the Action to
2.8% per year, and the progression from macroalbu- Control Cardiovascular Risk in Diabetes (ACCORD)
minuria to elevated plasma creatinine (178 μmoL) or trial suggests that very aggressive glucose control in
renal replacement therapy (RRT) occurred at a rate patients with established diabetes and either CVD or
of 2.3% per year. Ten years following the diagnosis additional cardiovascular risk factors may result in
of diabetes, the prevalence of microalbuminuria was increased mortality without a reduction in major car-
24.9%, the prevalence of macroalbuminuria was 5.3%, diovascular events. 13,14
and the prevalence of an elevated plasma creatinine
concentration or RRT was 0.8%. Patients with an ele-

Cardio Diabetes Medicine