Diabetic nephropathy and chronic kidney disease at a busy diabetes clinic: a study of outpatient care and suggestions for improved care pathways at a subspecialty specialist diabetic renal clinic.
Prior to establishing a specialist diabetic renal clinic in our unit, we studied across 12 months all 1845 patients attending one of our diabetes clinics with a serum creatinine >150 μmol/l. Diabetic control was examined along with renal function and cardiovascular risk using current audit standards. 74 such patients were identified (male:female 54:20 mean HbA1c 7.8% (sd ± 1.45) and age 64.2 years (± 12.8). 30 patients had creatinine >200 μmol/l and 15 >250 μmol/l. Using the chronic kidney disease classification, 33, 28 and 6 patients were in groups III, IV and V with 7 patients undergoing renal replacement therapy. 65% of patients met JBS2 audit standards of blood pressure using a mean of 2.93 agents (sd ± 1.43). Ace-inhibitors or angiotensin receptor blockers were used in 81% and 81% were on regular antiplatelet or anticoagulant therapy. Audit standard for total cholesterol and LDL were met in 89% and 97% of patients respectively. All patients identified in our study were in CKD class III-V and therefore we considered also alternative inclusion criteria. 136 patients had a urinary ACR ≥ 30 mg/mmol. Using this and/or the serum creatinine level above identified 197 patients from the clinic. This study shows that measurement of serum creatinine alone is not sufficiently sensitive but extended criteria identified a 10% subgroup who will now be offered detailed assessments and intensified therapies at a subspecialty in-house renal clinic. eGFR has recently been added to our computerised proforma and will enable us to further refine inclusion criteria.
Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, BT12 6BA. una.graham@belfasttrust.hscni.net
U M
UM
Graham
G M
GM
Magee
S J
SJ
Hunter
A B
AB
Atkinson
D000368:Aged; D000419:Albuminuria; D000554:Ambulatory Care Facilities / Q000458:organization & administration*; D003404:Creatinine / Q000097:blood / Q000652:urine; D003928:Diabetic Nephropathies / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D018450:Disease Progression; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D033183:Interdisciplinary Communication; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000458:organization & administration*; D009660:Northern Ireland; D012017:Referral and Consultation / Q000458:organization & administration*; D013038:Specialization
D003404:Creatinine