Navigating the kidney disease care cascade in type 2 diabetes: insights from the national diabetes registry

Abstract Background Diabetic kidney disease (DKD) is a common complication among people with type 2 diabetes (T2D) and is a leading cause of chronic kidney disease (CKD). Malaysia ranks among the highest diabetes-related CKD rates worldwide, and despite research emphasis on diabetes and its complications, the unmet needs for DKD care remain largely unexplored. This study aimed to identify the unmet need for diagnosis, treatment, and control of DKD using the care cascade among patients with T2D receiving follow-up care in government health clinics in Malaysia. Methods A cross-sectional analysis of the National Diabetes Registry (NDR) 2023 was conducted. Inclusion criteria were adult patients with T2D that received DKD screening or had a diagnosis of nephropathy. DKD was defined as either documented nephropathy in the NDR, or abnormal estimated glomerular filtration rate (eGFR) or albuminuria. Treatment was defined as the documented prescription of either angiotensin converting enzyme inhibitor (ACEi)/angiotensin-receptor blocker (ARB)/Sodium-glucose Cotransporter 2 inhibitors (SGLT2i)/ Glucagon-like peptide-1 receptor agonist (GLP1-RA) and statin, whereas control was defined as achieving glycosylated haemoglobin A1c (HbA1c) and blood pressure targets. Multivariable logistic regression was done to identify the determinants for unmet need at each stage. Results The prevalence of DKD among diabetic patients was 53.2% (56949/107099). The prevalence of total unmet need for care was 97.6%, with deficiencies observed across all stages; diagnosis (74.6%), treatment (27.9%) and control (86.8%). The two crucial gaps identified in this care cascade were for uncontrolled and undiagnosed DKD, with uncontrolled blood pressure identified as the main contributor for uncontrolled DKD. Risk factors for unmet need were female sex (adjusted odds ratio (AOR) 1.23–1.39), middle age (AOR 1.38–3.15), and hyperlipidaemia (AOR 1.10–1.52). Conclusions The DKD care cascade identified a notable gap in meeting care needs, with a consistent deficiency in care at each stage. This study findings serve as a benchmark and framework for the evaluation and improvement of DKD care in Malaysia. While addressing the factors associated with undiagnosed and uncontrolled DKD are crucial, further evaluation of home-based blood pressure should be done prior to intensifying control measures.