Improving the Standard of Care in Diabetic Kidney Disease

Abstract

Without careful management, people with type 2 diabetes mellitus (T2DM) are at risk of progressive kidney function decline, conferring increased risks of cardiovascular events, hospitalisations for complications, and impaired quality of life. Progression to kidney failure has further serious impacts upon quality of life and life expectancy. Medications such as sodium-glucose cotransporter-2 (SGLT2) inhibitors can effectively lower the risk of diabetic kidney disease (DKD), however the global impact of these agents is diminished by major challenges in evidence-based care delivery. This thesis explored practical solutions to help close the evidence-practice gap.

The first part examined current evidence-based care for DKD through synthesis of rapidly evolving clinical trial data, including a meta-analysis of kidney outcomes with a class of medications used in T2DM, dipeptidyl-peptidase-4 inhibitors, showing worse preservation of kidney function than with comparator medications.

The second part investigated medication adherence trends for people with T2DM commencing kidney-protective therapies. It demonstrated a critical need to support long-term adherence.

The third part explored barriers and facilitators to effective diabetes care, including to SGLT2 inhibitor use, through interviews with people with T2DM and multidisciplinary clinicians. It highlighted a need to provide better patient education about T2DM, strategies to prevent medication adverse effects, and practical adherence skills.

The fourth part investigated digital health technologies as scalable methods of delivering patient education and adherence support, including the design of a text message education and support program for new users of SGLT2 inhibitors, to be tested in an upcoming randomised controlled trial.

This body of work has significantly advanced medical understanding of strategies to close the evidence-practice gap in T2DM care and lays important groundwork for ongoing research in this field.