P176
SHOULD ALL PATIENTS WITH CHRONIC KIDNEY DISEASE AND DIABETES
MELLITUS BE TREATED IN A JOINT RENAL DIABETIC CLINIC?
Jonathan Wong1, 2, Tracey Maryan1, Jocelyn Berdeprado1 and Suresh Mathavakkannan1
1
Department of Nephrology, Lister Hospital, Stevenage
2
University of Hertfordshire
BACKGROUND: Management of patients with chronic kidney disease (CKD) and diabetes
mellitus (DM) is complicated. Both conditions can lead to different systemic complications and
CKD and DM commonly co-exist together in patients. Patients should ideally be followed-up in
a multi-disciplinary setting with joint diabetic and nephrology clinics to facilitate close
monitoring of renal function, dietary interventions, glycaemic control and streamline treatment
pathways. However, not all patients with CKD and DM progress to end stage kidney disease
and renal function may be monitored either in primary care or by the diabetes services. A joint
renal diabetic clinic is not available at our trust and patients are seen in separate nephrology and
diabetic clinics. We studied outpatient attendance patterns, rate of renal function decline and
other clinical parameters in patients with CKD and DM at our trust to determine the proportion
of patients with non-progressive and progressive CKD to assess potential need for development
of joint renal diabetic clinic at our trust.
METHOD: A cross-sectional survey was carried out on all patients with CKD and DM
registered in the renal database at our trust. Demographic and clinical parameters including
glycated haemoglobin (HbA1c), blood pressure, type of DM, urine protein: creatinine ratio
(urine PCR), medications and estimated glomerular filtration rate (eGFR) for the previous 5
years were collected. Patients who had a rate of decline in eGFR of more than 2ml/min/1.73m2
were defined as having progressive CKD. Patients who were also being followed up at the
diabetes clinic at our trust wereidentified.
RESULTS: Data was collected on 235 CKD patients with DM (mean age 65.8±14.4; 67.2%
male) attending nephrology outpatients at our trust. The proportion of CKD patients with Type
1, Type 2 and unspecified DM was 10.2, 79.6 and 10.2% respectively. Median eGFR was
41ml/min/1.73m2 (29.0-56.6 IQR). Median HbA1c was 56 (45.5-70 IQR), urine PCR was
36mg/mmol (13-143) and mean blood pressure was 137/73. Diabetic nephropathy was the
primary renal diagnosis in 81/235 (34.5%) patients. Approximately one third of patients (92/235
- 39.1%) had progressive declining eGFR, but only 39.1% (36/92) of these patients were being
followed up in the diabetic clinic. Conversely, in patients with diabetic nephropathy, 51.3% did
not have progressive kidney disease, potentially representing a group of patients who could be
monitored safely monitored in primary care or the diabetic clinic.Patients with progressive
diabetic nephropathy were more proteinuric than those without progressive CKD (91mg/mmol
vs. 21mg/mmol, p<0.001) but did not significantly differ in terms of age, weight, glycaemic
control or blood pressure control. In our original cohort, 18.7% (44/235) were lost to follow-up
from nephrology services, 36.4% (16/44) of this subset of patients continued to attend the
diabetic clinics and63.6% (28/44) were lost to follow-up from both diabetic and renal services.
One third (33.3%) of these had progressively declining renal function, representing 3.8%
(9/258) of total cohort of patients.
CONCLUSION: Not all patients with CKD and DM develop progressive renal disease.
Identifying patients (with low level proteinuria or slow declining eGFR) who could be safely
monitored in primary care or in the diabetic clinic may relieve pressure on nephrology
outpatient services and reduce hospital visits for patients. However, nearly half of all patients
with diabetic nephropathy develop progressively worsening kidney failure anda significant
proportion (39.1%) was not being seen in a diabetic specialist clinic, potentially missing out on
specialist interventions. Development of a joint diabetic renal servicecould streamline care and
improve management of these patients.