Targeting cardiorenal damage in type 2 diabetes

As rates of type 2 diabetes and prediabetes continue to soar, so too are rates of cardiorenal complications. What can we do to tackle this globally significant health challenge? For the third episode in our series ‘The briefing room’, under the sure-footed chairmanship of Professor Francesco Giorgino, five esteemed experts in the field join forces to explore cardiorenal metabolic challenges in type 2 diabetes.

The alarming rise in the prevalence of type 2 diabetes is mirrored by a growing understanding of the complexity of its associated complications. “Obviously, we are aware that type 2 diabetes is often associated with cardiovascular disease, but also with chronic kidney disease,” says Professor Francesco Giorgino. “And we’ve also discovered that cardiovascular disease is not just atherosclerotic cardiovascular disease. As diabetologists we have learned more and more about the existence of heart failure of different types.” 

The figures make alarming reading. Up to three out of 10 people with type 2 diabetes are expected to develop heart failure during their lifetime. That’s around 150 million people. Globally, around 56% of people with type 2 diabetes show signs of kidney disease – an important driver of cardiovascular disease. The good news, though, is the recent availability of new treatments which, as Francesco describes them, are capable of interfering with the natural course of this organ damage. So, given recent advances in knowledge and treatment, what is the best approach for a person with type 2 diabetes with signs of organ damage?

Getting to grips with such a wide-ranging topic requires a wide range of expertise – embodied here in a panel that includes nephrologist and diabetologist Per-Henrik Groop, endocrinologist and angiologist Eberhard Standl, diabetologist and professor of nutrition Paul Valensi, and endocrinologist with a special interest in diabetes, lipids and cardiovascular risk, Dr Roopa Mehta.

For Roopa, it’s important that we should take a holistic approach. “It’s about integral care and trying to give a more individualised approach to our patients. Obviously, glucose control is extremely relevant. We must do this. But we need to look at the patient in total. The minute they have organ damage we know that there are obviously other comorbid conditions that are probably influencing this. It’s not just sugar, it’s blood pressure control, lipid management, weight management. So, we need to look at the patient in a more holistic manner and control all these factors in order to prevent the progression of this kind of organ damage.”

Such an approach is one of the central messages in recent guidelines for type 2 diabetes management from the ADA/EASD, which prioritise evaluation of patients for cardiorenal risk – and the prompt initiation of newer medications such as SGLT-2 inhibitors and GLP-1 receptor agonists. This episode of the briefing room takes on many of the key associated issues – from the question of how to identify those with ‘silent’ heart disease to the potential interventions and targets physicians should aim at when treating people with type 2. Says Francesco: “That includes weight control, blood pressure control and lipid control – in addition, of course, to glucose lowering, which remains a cornerstone of our approach. We’ve also discussed the recent evidence around GLP-1 receptor agonists, SGLT-2 inhibitors and the recent antagonist to the mineralocorticoid receptor, finerenone. And we’ve tried to think about what could happen if we combined these agents together in terms of clinical outcomes, especially referring to the heart, vessels, the kidney and the overall health of our patients.”

Get the full story in the third episode of ‘The briefing room’, ‘Cardiorenal metabolic challenges in type 2 diabetes’, launching today on Horizons.  

For more on the ADA/EASD consensus report on type 2 diabetes management, enrol on our course ‘Management of hyperglycaemia in type 2 diabetes’.

Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.