Innovations to Improve the Primary and Secondary Care Collaboration in the

Management of Diabetic Related Kidney Disease

Julie Lewis DSN.

Renal and Diabetes Centre

Glan Clwyd Hospital

Denbighshire

North Wales.

AIMS

• Review incidence / prevalence of Diabetes and Diabetic Nephropathy

• Share experience in the development of our Diabetic Nephropathy Service to date

•

DIABETIC NEPHROPATHY

• Gradually progressive condition associated with increased risk of cardiovascular disease, significantly impacting mortality if left to progress without detection or treatment.

• Incidence: Increasing.

• Prevalence : 10 – 40%• Leading cause of ESRD.

• Diabetic nephropathy is now the single most common cause of CKD in the US and Europe.

What is Diabetic Renal Disease? • Dipstick – ve: Microalbuminuria 1) Albumin - >20mg/l 2) Albumin Excretion Rate (AER) : 20- 200µg/min 3) Albumin Creatinine Ratio(ACR) - >2.4

Males >3.5 mg/mmol cr Females • Dipstick –ve: renal impairment without

proteinuria : MacIsaac RJ et al Nonalbuminuria Renal Insufficiency in Type 2 Diabetes Diabetes Care 27:195-200

• Dipstick +ve: Macroalbuminuria(+/- Renal Impairment)

AER >200µg/min or ACR >30 or 24 urinary protein >0.3g/day ( diabetic nephropathy)

Innovation 1.2001 - 2002

• 6 Primary Care doctors (GPs) + Practice Nurses and Receptionists

• Renal/Diabetes Research Nurse Specialist• Nephrologists• Diabetologists• Radiologist• Chemical Pathologist• Audit Administrator

Objectives

• Primary Care audit to establish no.T2DM screening for microalbuminuria

• Prevalence of MA in T2DM in our region• Establish the best testing method (accuracy

and compliance)• Establish whether effective screening and

management for MA in T2DM can happen in Primary Care

Main Findings• Patients were not being screened for MA • Using AER had low patient compliance

(30%)• What was our prevalence of MA? – 22%• Lab acquired equipment for ACR(patient

compliance improved to 83%)• Produced local screening and treatment

guidelines for diabetic renal disease

Screening for Diabetic Renal Disease

Early Morning Urine for Albumin / Creatinine Ratio

ACR (mg/mmol cr)

< 2.5 Men

< 3.5 Women

> 2.5 Men

> 3.5 Women

Repeat ACR

Annually

Repeat ACR within 1 Month

REPEAT ACR

< 2.5 Men

<3.5 Women

>2.5 Men

>3.5 Women

< 2.5 Men

< 3.5 Women

> 2.5 Men

> 3.5 Women

Start:1 ACEi or A11RA

2 Aspirin •Ace-I: Angiotensin Converting Enzyme Inhibitor

•A11RA:Angiotensin 2 Receptor Antagonist

Treatment Guidelines for Diabetic Renal Disease

The following ACE inhibitors (ACEi) and Angiotensin II Receptor Antagonist (AII RA) are

licensed for treatment of diabetic renal disease – accepted by D&T and LHB Drug Start Dose (mg) Target Dose (mg)

Lisinopril 2.5 >10

Ramipril 2.5 10

Irbesartan 150 300

Losartan 50 100

Titrate start dose at 2 weekly intervals, to target dose. Check BP at each dose increment and reduce dose if symptomatic hypotension develops.Repeat ACR or 24hr urinary protein every 3-6 monthly.

Check U&Es before, 1 week after initiating and after dose increase of ACEi or AIIRA. STOP ACEi or AIIRA if serum creatinine rises c GFR drops >20% above baseline or if hyperkalaemia (potassium >6.0mml/l) develops.

Aim for the following targets and advise patient to stop smoking: BP < 130/70

HbA1C < 7.0 Cholesterol < 5.0mmol/l

Refer to diabetic nephropathy clinic if a) creatinine >150µmol/l or rises >20% above baseline b) micro or macroalbuminuria continues to rise , despite target doses of ACEi or AIIRA c) nephrotic syndrome develops. Arrange renal ultrasound scan.

Do not use ACEi or AIIRA in pregnancy or patients planning pregnancy, bilateral renovascular disease, aortic stenosis .

Impact

• Results of this study with screening and treatment guidelines communicated to all GP’s and P/N’s

• No. of screening tests for Microalbuminuria using the ACR increased

Innovation 2

• Satellite clinics for T2DM patients identified with microalbuminuria

• Opportunity to develop skills and knowledge in Primary care

• Reinforced screening and treatment guidelines for diabetic kidney disease

SATELLITE CLINIC INTERVENTIONS

N=62

88% Needed life-modifying advice

59% Medication changes made

30% Had renal impairment and

transferred to Hospital clinic:• US Kidneys - all patients

• Renal MRA - 9 patients (no RAS)

• Renal Biopsy - 4 patients

Findings

• Simple innovative measures improved the primary secondary care interface and enhanced the screening and management of diabetic renal disease and its associated risk factors in our region

• Specialist support to implement these measures requires continuity to be fully effective, but has the potential to enable the majority of people with Diabetic Renal Disease to be effectively managed with evidence based guidelines in primary care.

Impact

• Raised awareness

• Improved communication

• Coinciding with GMS contract

• Increase ACR screening further

NEPHROPATHY SCREENING

0

100

200

300

400

500

600

700

800

Jan-

96

May

-96

Sep-9

6

Jan-

97

May

-97

Sep-9

7

Jan-

98

May

-98

Sep-9

8

Jan-

99

May

-99

Sep-9

9

Jan-

00

May

-00

Sep-0

0

Jan-

01

May

-01

Sep-0

1

Jan-

02

May

-02

Sep-0

2

Jan-

03

May

-03

Sep-0

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Jan-

04

MONTH

NU

MB

ER

OF

SA

MP

LE

S B

Y M

ON

TH

MALB

ACR

ALL

MA Testing – on the Increase!

Impact

• Clear referral guidelines congested Secondary care diabetic nephropathy clinic

• Unacceptable waiting list for this high risk group

Innovation 3

• Increased referrals to secondary care.

• Review current service.

• Essential to re-structure service provision for diabetic nephropathy.

Clinic Pathway

Referral

Primary CareSecondary care diabetes clinic

Specialist Physician -New patient assessment

•Investigation•Diagnosis

Treatment Plan

Nurse-led Review Physician review

Low ClearanceClinic

Supported dischargeTo P.C

Continued secondary care review

Developing a Nurse-led Diabetic Nephropathy Review Service

• Professional development • Education – skills and knowledge

– Competence – Patient protection

• Treatment plan – Evidence based• Optimise Modifiable Risks – reduce

progression of Diabetic Nephropathy• Structured patient education – strategies for

self-management

Nurse-led Review• Implement action plan

• Inclusive – sharing knowledge

• Follow up visits to evaluate effectiveness of clinical interventions

• Pre testing• Inclusive – discussing results and treatment plan –

increasing understanding

• Telephone clinics – glycaemic control• Continuity – supporting compliance and optimising control

• Promote partnership approach to behaviour / lifestyle changes

• Realistic goal setting• Motivation• Responsibility

Effective strategies for Self-Management

• Realistic• Collaborative• Patient centred• Identify barriers for self-management

• Knowledge• Helplessness / frustration• Grieving for loss of health – denial / indifference

• Continued Support / encouragement

Nurse-led Review - Collaboration

• Promote knowledge and understanding

• Offer advice

• Coaching and encouragement

• Empowerment – informed decision making

• Weigh up options• Make choices

Nurse led Clinic - Benefits

• Cost effective

• Increased diabetic nephropathy review slots by 250 per year

• No DNA’s

• Audit of clinical effectiveness and patient satisfaction - Summer 2006

• Encourage Practice Nurses to attend clinic

Nurse-led Clinic Limitations

• One session per week – clinic• One session per month – telephone

clinic• Collaboration between Primary and

Secondary care hindered by poor IT provision

• Numbers still increasing - ? Group education

Link with Policy

• Diabetes NSF / Renal NSF / NICE / Chronic Disease Management strategies– Early detection– Delay progression– Structured education / patient

empowerment

• Effective CDM = Shared care

Shared Care?• Increasing numbers • Economic drivers• CDM policy• Accessibility• Evidence based intervention strategies to be

addressed largely in Primary care• Primary care need to be assured that specialist

secondary care services can be accessed for their CD patients who– Fail to respond to treatment guidelines– Deteriorate despite recommended target treatment

CKD: A Typical GP Practice of 10000CKD: A Typical GP Practice of 10000

Stage 1

Stage 5

Stage 4

Stage 3

Stage 2

460

60

6

380

90

60

15

30

eGFReGFR

Conclusion• Series of innovations since 2001 to

manage diabetic nephropathy in our region – ongoing process

• Enhanced the collaboration between Primary and Secondary care to manage this condition

• Developing approaches to promote self-management in line with CDM strategy

• ACR testing – likelihood of unnecessary duplication

Thank You