The Road To Co-management Of Diabetes, Heart And Kidney Joint Prevention

Diabetes, cardiovascular disease, and chronic kidney disease (CKD) are the "main forces" of chronic diseases in China, and they are also the "three mountains" that China's disease management urgently needs to overcome. Clinically, the three diseases of "sugar", "heart" and "kidney" are interrelated. When one of the diseases is not well controlled, the risk of the other two diseases will increase, which will lead to the deterioration of the overall condition. 

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To accelerate the joint prevention and management of the three major chronic diseases of diabetes, heart, and kidney, and help realize the goal of "Healthy China 2030", the first "CaReMe-AstraZeneca Sugar, Heart and Kidney Summit Forum" was grandly opened in Shanghai on April 22!

April 22, 2023, Professor Wang Weiqing from Ruijin Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Professor Chen Lulu from Union Hospital Affiliated with Tongji Medical College of Huazhong University of Science and Technology, Professor Peng Yongde from the First People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Beijing Chaoyang Hospital Affiliated to Capital Medical University Professor Wang Guang, Professor Feng Bo of Shanghai Dongfang Hospital, Professor Shi Yongquan of Shanghai Changzheng Hospital, Professor Hou Shupeng of Zhuozhou Hospital, Professor Shi Ling of Shanghai Putuo District Health Affairs Management Center, Yang Shengbin of AstraZeneca China Cardiovascular, Kidney, and Metabolism Division Mr. Gathered in the Diabetes Special Forum. 

Recalling the past, looking at the present, looking forward to the future, gathering together and starting again, from guideline interpretation to clinical practice, discussing the current situation and future of diabetes, heart, and kidney chronic disease diagnosis and treatment in multiple dimensions, bringing an academic storm of wisdom fusion, a discipline A glorious journey of fusion.

In his speech, Mr. Yang Shengbin said that in China, there are a large number of diabetic patients, and the disease awareness rate, treatment rate, and control rate are all low, and many patients will have diabetes, heart, and kidney comorbidity. Previously, AstraZeneca had launched innovative drugs such as sodium-glucose cotransporter-2 inhibitor (SGLT-2i) in this field. 

The compound preparation of SGLT-2i and metformin will also be launched in China in the second half of 2023. In the future, we will also launch a solution for the whole process of disease management based on the common risk factors of diabetes, heart, and kidney, reduce the risk of diabetes, heart, and kidney disease, and delay the progression of the disease. It is a great honor to have the opportunity to discuss the comprehensive management of diabetic patients with domestic authoritative experts in the field of endocrinology. I wish this meeting a complete success.

Professor Wang Weiqing mentioned in his speech that if the treatment effect of diabetes is not good, patients often have complications such as cardiovascular and kidney. It is the responsibility of our endocrinologists to explore a better treatment plan with the power of three disciplines, and it is also the responsibility of the majority of patients. earnest hope. The content of this conference is exciting and rich. I believe that the experts and scholars participating in the conference will learn something.

At the beginning of the meeting, Professor Wang Weiqing first gave an academic sharing on "Focusing on the Heart and Kidney, Metabolic Co-management - 2023 National Standardized Metabolic Disease Management Center (MMC) Guidelines Update Interpretation". Professor Wang Weiqing pointed out that the 2019 edition of the MMC guideline has been polished, clarified the path, and standardized the plan. 

The "Guidelines for the Management of Metabolic Diseases (Second Edition)" issued by the National Standardized Center for Metabolic Disease Management is more feasible and valuable.  The guidelines mention that glycosylated hemoglobin (HbA1c) <7%, blood pressure <130/80mmHg, and low-density lipoprotein cholesterol (LDL-C) <2.6mmol/L can be used as comprehensive control goals for metabolic diseases in MMC [1]. 

During the treatment of type 2 diabetes mellitus (T2DM), blood glucose management should be given equal attention to cardiorenal risk management. Early combination therapy can increase the durability of the hypoglycemic effect and take into account clinical benefits such as body weight and cardiorenal protection [2-5]. Oral hypoglycemic agents represented by metformin, SGLT-2i, and dipeptidyl peptidase-4 inhibitor (DPP-4i) can cover multiple pathophysiological mechanisms of diabetes and are suitable for most T2DM patients.

Subsequently, Professor Feng Bo discussed the comprehensive management strategies for diabetic patients based on the latest guidelines. Professor Feng Bo pointed out that in the early guidelines, intensive blood sugar control was at the top of diabetes treatment. However, a large-scale meta-analysis[6] suggested that intensive sugar control failed to significantly improve the mortality outcome, and the STENO-2 study[7] confirmed that comprehensive management of multiple risk factors can reduce the risk of cardiovascular events and death, and reduce microvascular complications. risk of disease progression. 

At present, the academic community has made it clear that the hazards of diabetes mainly come from its cardiorenal complications [8], and there is a two-way risk association between cardiorenal complications [9]. Therefore, the concept of diabetes management has developed from simple hypoglycemia to comprehensive management of risk factors such as control of blood sugar, blood pressure, and blood lipids, and then to the stage of improving heart and kidney outcomes.

At present, the treatment path of T2DM recommended in international guidelines has changed accordingly, emphasizing patient-centered and cardio-renal risk assessment first [10-11]. The latest "Diabetes Medical Diagnosis and Treatment Standards (2023 Edition)" [12] released by the American Diabetes Association (ADA) mentioned that to reduce the cardiovascular risk of high-risk patients with diabetes, in terms of drug selection, SGLT-2i or glucagon Peptide-like peptide-1 receptor agonist (GLP-1RA) has firmly jumped to the first-line position [12]. 

Professor Feng Bo emphasized that SGLT-2i and/or GLP-1RA should be selected for patients with T2MD who have been diagnosed with atherosclerotic cardiovascular disease (ASCVD) or combined with its high-risk factors; For T2DM patients, SGLT-2i should be the first choice. If SGLT-2i is intolerable or contraindicated, then GLP-1RA should be used.

Joint prevention and co-governance, comprehensive management benefits more

Statistics show that the prevalence of diabetic kidney disease (DKD) in China has reached 21.8%, which should not be underestimated, and the situation of its prevention and treatment is already very serious. Professor Shi Yongquan focused on the whole process of DKD management, from diagnosis to treatment, and discussed DKD in all aspects. 

According to Professor Shi Yongquan, China currently faces four major difficulties in CKD: 1) Insufficient cognition, screening, and diagnosis; 2) Low rate of treatment and control, low rate of SGLT-2i prescription; 3) Low treatment compliance; 4) Lack of Awareness of multidisciplinary diagnosis and treatment.

In this regard, Professor Shi Yongquan pointed out the solution: 1) Early identification of DKD can be carried out by combining pre-identification means with routine screening; 2) Meta-analysis [13] shows that early initiation of SGLT-2i treatment of kidney is more beneficial, so for DKD, it is necessary to detect and intervene as early as possible, change the treatment concept centered on hypoglycemia, and choose a treatment plan that can help reduce renal events in T2DM; 3) High frequency of medication is one of the main factors that reduce patient compliance. 

Dosage compound preparation (FDC) is beneficial to improve patients' treatment compliance [14-15]; 4) Multidisciplinary cooperation is the general trend, and multidisciplinary management of DKD patients can significantly improve HbA1c and estimated glomerular filtration rate (eGFR), to help patients achieve more benefits.

When sharing the comprehensive benefits of SGLT-2i combined with metformin therapy, Professor Wang Guang pointed out that the HbA1c compliance rate of Chinese diabetic patients is low, and with the prolongation of treatment time, the compliance rate of monotherapy gradually decreases [16-19]. 

In this regard, multiple guidelines and consensus[12,20-21] recommend that combined therapy should be initiated promptly In terms of drug selection, SGLT-2i combined with metformin has complementary mechanisms, covers multiple causes of diabetes, and has the advantages of a strong hypoglycemic effect, cardiorenal protection, and multiple benefits [22]. 

The FDC dosage form of SGLT-2i combined with metformin has the same curative effect as the ree combination [23], which helps to improve patient compliance and satisfaction with treatment and is less costly. It is the preferred combination treatment for diabetic patients.

Professor Peng Yongde, when discussing the multiple benefits of comprehensive management and control of T2DM around diabetes combined with cardiovascular risk factors, said that hypertension and hyperlipidemia are the main risk factors for heart and kidney complications in diabetic patients [24]. Promote the co-management of the three high levels, and clarify the standardized management goals and action goals.

For diabetic patients with hyperlipidemia, it is necessary to actively lower blood sugar and lipids. For primary prevention of diabetic patients aged 40-75, it is recommended to add moderate-intensity statins based on lifestyle [25], and multiple blood lipid indicators such as LDL-C and triglyceride (TG) should be taken into account in lipid-lowering treatment while focusing on drug safety [26]. 

For diabetic patients with hypertension, SGLT-2i can effectively reduce blood sugar and blood pressure and can be used as a cornerstone treatment drug for T2DM patients with hypertension [29].

Hierarchical diagnosis and treatment lead the future

In the discussion session, Professor Shi Yongquan, Professor Hou Shupeng, and Professor Shi Ling focused on "the pain points and difficulties in the long-term risk management of diabetes in primary medical institutions", "points for attention in the standardized application of new hypoglycemic drugs such as SGLT-2i", "Specific Measures to Strengthen Cooperation between Primary Medical Institutions and Tertiary Hospitals" to share the experience. 

Thoughts are intertwined, wisdom collides, one person's power is limited, and everyone's power is sufficient, and we will work together to lead the new future of hierarchical diagnosis and treatment.

Epilogue

The "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition)" [21] clearly states that the risk of cardiovascular disease in patients with diabetes increases by 2 to 4 times. In addition, about 20% to 40% of diabetic patients have DKD, and DKD has become the main cause of CKD and end-stage renal disease [21]. Therefore, for diabetic patients, in addition to effectively controlling sugar, it is also necessary to avoid heart and kidney damage to the greatest extent.

The three chronic diseases of diabetes, heart, and kidney were terrible in the past, curable now, and promising in the future. It is the 30th anniversary of AstraZeneca's entry into China. Let us take the guideline as the guide, take the practice as the basis, gather strength with responsibility, lead the future with wisdom, and make steady and long-term progress on the road of joint prevention and co-management of diabetes, heart, and kidney!

The Mechanism of Cistanche Treatment Kidney disease

Cistanche is a traditional Chinese herb that has been used for centuries to treat various health conditions, including kidney disease. The exact mechanism by which Cistanche treats kidney disease is not fully understood, but it is believed to have several beneficial effects on the kidneys.  One way that Cistanche may help treat kidney disease is by increasing blood flow to the kidneys. This can help to improve overall kidney function and reduce the risk of kidney damage. Cistanche may also have a protective effect on the kidneys, helping to prevent damage from toxins or other harmful substances in the body.

Additionally, Cistanche is thought to have anti-inflammatory properties, which may help to reduce inflammation in the kidneys and improve kidney function. It may also have antioxidant effects, which can help to protect the kidneys from damage caused by free radicals. Overall, while the exact mechanism by which Cistanche treats kidney disease is not fully understood, it is believed to have a range of beneficial effects on kidney function and health.

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