Responding to the Challenges in the Management of Diabetic Renal Disease.
J Lewis, M Kumwenda, J Platts
Glan Clwyd Hospital, Wales
Introduction: Global estimates expect the doubling of T2DM over the next 20 years. Up to 30% will develop Diabetic kidney disease and >50% will die due to cardiovascular disease. Microalbuminuria (MA) is the earliest sign of diabetic kidney disease. Screening, early detection and treatment will reduce the risk of progression to end stage renal disease (ESRD). We described a series of innovations introduced to meet the challenges of management for diabetic kidney disease in a presentation at BRS in June 2004 and now have the results of the project.
Objectives. To determine the prevalence of MA and implement an integrated approach to improve the management of diabetic kidney disease in our region.
Method.2001 – A multi-disciplinary group formed of 6 GP practices, Research Nurse, Diabetologist, Nephrologist, Chemical Pathologist and Audit Administrator.
Study 1. Primary care case notes were reviewed to determine proportion of kidney disease, prevalence and treatment of cardiovascular risk factors, MA and glycaemic control.
Study 2. A cohort of patients was screened for MA using Albumin Excretion Rate (AER-timed overnight urine collection). A new test was introduced, Albumin Creatinine Ratio (ACR-early morning spot urine test), patient compliance with the two tests was compared.
Study 3.Treatment algorithms and target guidelines were officially ratified. Patients with MA were reviewed in satellite clinics in Primary care by diabetes research nurse and renal / diabetes specialist.
Results.
Study 1. 844 patients 82% had no previous screening for MA. Study 2. 190 people screened showed 18% had MA. 30% complied with AER testing. Compliance improved to 83% when ACR was used to screen for MA. Study 3. In satellite clinics, there were 40 male and 21 female with duration of diabetes >5years in 89%. By the end of 12 months, 4 died, 30% had BMI>30(no improvement) 47% had HbA1c <7.5% (no improvement). 48% had systolic BP<135mmHg (31% improvement). MA was normalised or reduced by at least 50% in 53% of cases. 67% had cholesterol<5mmol/l. 88% needed treatment changes. 27% had renal impairment and were transferred to Secondary care diabetic nephropathy clinic. Since the project commenced, MA testing has increased in our region from 100 per month to 700 per month in 2004.