Does Referral of Diabetic Nephropathy to a Nephrologist make a difference?
M Bairy, S Siddiqui, S Bhandari,
Problem:
Diabetic nephropathy has major health, social and economic consequences. It affects approximately one third of patients
with an increasing number of diabetic patients requiring renal replacement
therapy. The recent National Service Framework suggests early referral of
diabetic patients with renal impairment.
Purpose: The question arises as to what stage referral from diabetologists is
most appropriate and is it beneficial.
Design: We carried out a retrospective pilot study of consecutive patients
referred from specialist diabetic clinics to the renal service with impaired
renal function. We examined blood pressure control, haemoglobin levels and use
of ACE-inhibitors or angiotensin receptor blockers.
Results: 32 patients, 23 male, 9 female (aged from 27 to 81 years of age)
were referred over the course of the study.
Of the 32 patients only 9 had acceptable blood pressure according to
recommended targets (less or equal to 130/80). Fourteen patients were referred
when the serum creatinine was greater than 200 mmol/L while the rest were between 150 and 200 mmol/L. Thirty out of 32
patients were either on an ACE inhibitor or A2 receptor antagonist within one
year of referral compared to 18 pre – referral. Mean haemoglobin at referral
was 10.37g/dL.
In the
subsequent year while under the care of the Nephrologists 24 out of the 32
achieved target blood pressure (systolic blood pressure of less than 130 or
10mmHg lower than referral value). In terms of serum creatinine no patient
reached the composite end point of doubling of baseline serum creatinine or
onset of end stage renal disease as indicated by the initiation of dialysis
within one year of referral. Mean Haemoglobin had risen to 11.02g/dL.
Conclusion: This small study suggests nephrological intervention may be of value
in optimising blood pressure control and ensuring the introduction of
angiotensin/ACE inhibitors. This could potentially be primary and secondary
prior to referral to allow optimisation of patients prior to nephrological
referral
.Relevance: Nephrological intervention may delay the need for dialysis therapy and limit the rising creatinine and improve Haemoglobin levels. The introduction of a joint clinic may be useful.