Mortality from diabetic kidney disease before and during the COVID pandemic

Published Date: 04th September 2023

Publication Authors: Lewis GA, Cardwell J, Hardy KJ

Background and aims
We have previously published 5-and 10-year audits from our UK diabetes kidney clinic reporting outcomes comparable to those in landmark trials of diabetic kidney disease in broadly similar patients. This 2023 (20-year) audit again showed practice consistent with NICE, ADA and Kidney Disease Improving Global Outcomes guidelines, but with sharply increased mortality compared with our previous audits and landmark trials. Our clinic continued face-to-face throughout the pandemic, but attendance was reduced by patient self-isolation during national lockdowns.

Material(s) and Method(s)
We studied 298 patients, mean (SD) age 60 (14) years and mean diabetes duration 16 (10) years in 2125 person-years follow-up; 65% were male and 10% were smokers; median (range) eGFR was 34 (4-90) and 77 (25%) had end-stage renal disease (ESRD): 5 transplant, 44 haemodialysis, 4 continuous ambulatory peritoneal dialysis and 24 conservative treatment; 50% had atherosclerotic cardiovascular disease (ASCVD) at baseline.

Result(s)
Median latest BP was 135/67 and median HbA1c 58 (31-130) mmol/mol; median LDL-cholesterol was 1.58 (0.57-6.42). Renin-angiotensin system (RAS) blockade status was known in 296 (99%): it was contraindicated in 75 (25%); reduced (hyperkalaemia) in 76 (25%) and reduced (low eGFR) in 71 (24%), leaving 148 eligible for maximum dose treatment, of whom 93% were on maximum single-agent RAS blockade. Median eGFR decline was 0.14 (-1.75-4.67) ml/min/month and ASCVD incidence was 1.65 per 100-person-years. Incident ESRD and mortality were high at 11.1 and 8.97 per 100-person-years respectively. A steep rise in mortality after 2019 prompted us to assess mortality pre-and since-COVID (arbitrarily defined as before and after 1st January 2020). The table shows increased mortality and eGFR decline since COVID, despite the cohorts before and since COVID being otherwise clinically very similar. Access to death certification was available in 119/140 (85%) who died, and in only 2 of these (1.6%) was COVID mentioned on the death certificate.

Conclusion(s)
These data appear to show an increase in mortality and renal decline in the years following the start of the COVID pandemic. This increase cannot be explained based on typical clinical risk factors, diabetes kidney disease clinic care or COVID infection itself. Prompt examination of other diabetic kidney disease cohorts is needed to look for similar ostensibly COVID-associated excess deaths.

 

Lewis, GA; Cardwell, J; Hardy, KJ. (2023). Mortality from diabetic kidney disease before and during the COVID pandemic. Diabetologia. 66(Suppl 1), pp.S466-S467. [Online]. Available at: https://doi.org/10.1007/s00125-023-05969-6 [Accessed 12 January 2024]

 

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