title: Early referral of Type 2 diabetic patients: are we ready for the assault?
abstract: BACKGROUND
  Elderly diabetics on dialysis are dramatically increasing in number. Their late referral reduces efficacy of therapeutic interventions; early referral is fundamental for their survival on dialysis. However, need for nephrological follow-up in case of early referral is not assessed. The objective was to define the need for follow-up in the nephrology setting of Type 2 diabetics, according to the early referral criteria of serum creatinine > or = 1.5 mg/dl or macroproteinuria.
  
  
  METHODS
  The setting of the study was an outpatient diabetic care unit (University of Torino), where approximately 25% of the Type 2 diabetics of a 900,000-inhabitant city (Torino, Northern Italy) were followed. At the time of the study (1998-1999) the unit followed 5182 Type 2 diabetics whose serum creatinine and proteinuria were tested at least yearly. A total of 3826 prevalent and 478 incident patients with one or more analyses in the same laboratory were included in the study. Demographic data were not statistically different between selected and excluded patients. We calculated the stepwise need for nephrological follow-ups calculated according to our usual policy (4-12 evaluations/ year, on serum creatinine and proteinuria, and 30 min/evaluation).
  
  
  RESULTS
  The prevalence of increased serum creatinine and macroproteinuria was high (in the prevalent cohort: serum creatinine > or = 1.5 mg/dl, 8.1%; proteinuria 0.3 g/day, 25.2%; serum creatinine > or = 3 mg/dl, 1.2%; nephrotic proteinuria 3.4%). Projecting data to the entire unit, with adherence to our evaluation protocol, early nephrological follow-up of Type 2 diabetics requires approximately 1300 h/year (one full-time nephrologist); five nephrologists are needed for our city, and 24 for the region (4350 000 inhabitants).
  
  
  CONCLUSIONS
  Early nephrological referral and follow-up of Type 2 diabetics is time consuming and expensive. Meeting the outpatient care needs of this critical cohort requires considerable resources.
authors.affiliation: Cattedra di Nefrologia, Department of Internal Medicine, University of Torino and Azienda Ospedaliera San Giovanni Battista della città di Torino, U.O.A.D.U. Nefrologia, Dialisi e Trapianto, Italy. gbpiccoli@yahoo.it
authors.forename: Giorgina Barbara
authors.initials: GB
authors.lastname: Piccoli
authors.forename: Giorgio
authors.initials: G
authors.lastname: Grassi
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Mezza
authors.forename: Massimo
authors.initials: M
authors.lastname: Gai
authors.forename: Candida
authors.initials: C
authors.lastname: Iacuzzo
authors.forename: Francesca
authors.initials: F
authors.lastname: Bechis
authors.forename: Luigi
authors.initials: L
authors.lastname: Biancone
authors.forename: Alberto
authors.initials: A
authors.lastname: Jeantet
authors.forename: Franco
authors.initials: F
authors.lastname: Dani
authors.forename: Paolo Cavallo
authors.initials: PC
authors.lastname: Perin
authors.forename: Giuseppe Paolo
authors.initials: GP
authors.lastname: Segoloni
mesh_terms: D015415:Biomarkers / Q000097:blood / Q000652:urine; D003404:Creatinine / Q000097:blood; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D003928:Diabetic Nephropathies / Q000453:epidemiology / Q000628:therapy*; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007558:Italy / Q000453:epidemiology; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000401:mortality / Q000628:therapy*; D008991:Monitoring, Physiologic; D010044:Outpatient Clinics, Hospital; D015995:Prevalence; D011507:Proteinuria / Q000097:blood / Q000453:epidemiology; D012017:Referral and Consultation; D006435:Renal Dialysis; D013997:Time Factors
chemical_list: D015415:Biomarkers; D003404:Creatinine