Early referral of Type 2 diabetic patients: are we ready for the assault?
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.
Piccoli
Giorgina Barbara
GB
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
Grassi
Giorgio
G
Mezza
Elisabetta
E
Gai
Massimo
M
Iacuzzo
Candida
C
Bechis
Francesca
F
Biancone
Luigi
L
Jeantet
Alberto
A
Dani
Franco
F
Perin
Paolo Cavallo
PC
Segoloni
Giuseppe Paolo
GP
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
D015415:Biomarkers; D003404:Creatinine