Transcript PRESENTATION TITLE

What do the guidelines say and
how will they affect day-to-day
management of CKD in people
with diabetes?
SECTION I
These slides were sponsored by Janssen and developed in conjunction with the BRS CKD Strategy Group, following an advisory board that
was organised by Janssen. Bedrock Healthcare Communications provided editorial support to members of the advisory board in developing
the slides. Janssen reviewed the content for technical accuracy. The content is intended for a UK healthcare professional audience only.
JOB CODE PHGB/VOK/0914/0018h
Date of preparation: January 2015
Objectives and background for this learning resource
Introduction:
This learning resource has been developed as part of a medical education initiative supported by
Janssen. The content of this slide kit has been developed by an advisory board of renal physicians, GPs
and specialist nurses. The panel of experts includes members of the British Renal Society Chronic Kidney
Disease (CKD) Strategy Group. Bedrock Healthcare, a medical communications agency, has provided
editorial support in developing the content; Janssen has reviewed the content for technical accuracy.
Educational objectives:
•
To provide clear and applicable clinical guidance on chronic kidney disease (CKD) in people with type
2 diabetes to primary care healthcare professionals
•
To advise primary healthcare professionals on what people with diabetes need to know about their
own condition with relation to CKD
Usability objectives:
•
To provide essential, relevant and up to date information in concise presentations
•
To enable primary healthcare professionals to locate, select and use the content of the learning
resource, as appropriate to their needs
•
To enable secondary care experts in CKD to refer their primary care colleagues to the resource
1
Contents overview
This learning resource comprises the following 10 sections (A-E):
Section A
Introduction and overview of chronic kidney disease (CKD) in people
with diabetes
Section B
Long-term impact of diabetes and the importance of optimal
management of the condition
Section C
Pathophysiology of diabetic nephropathy & risk factors for the
development of CKD
Section D
Appropriate monitoring for complications of diabetes in primary care –
CKD as one of these complications
Section E
Prevention of diabetic kidney disease
2
Contents overview (cont.)
This learning resource comprises the following 10 sections (F-J):
Section F
Optimal management of diabetic kidney disease:
hypertension and glycaemia
Section G
How to involve people with diabetes and CKD in their own care – what
information must they have to manage their own condition effectively?
Section H
What does the future hold for a person with well-managed diabetes
and CKD?
Section I
What do the guidelines say and what do they mean in terms of the
day-to-day management of CKD in people with diabetes?
Section J
Sources of further information and reading list
3
Section I – 3 key learning objectives
• Treatment of people with diabetes and CKD should be informed by the
guidelines, but individualised accordingly
• An understanding of which guidelines are most appropriate for treating people
with diabetes and CKD
• Awareness of the Quality and outcomes Framework (QoF)
4
Relevant Guidelines
The guidelines that are most relevant to the treatment of people with
diabetes and CKD are listed below
UK Guidelines
NICE CG87 type 2 diabetes guidelines
Issued May 2009, modified December 2014
NICE CG182 CKD guidelines
July 2014
NICE CG169 acute kidney injury guidelines
Issued August 2013
UK Renal Association CKD guidelines
5th Edition, 2009-2011
European Guidelines
Position Statement of the American
Diabetes Association (ADA) and the
European Association for the Study of
Diabetes (EASD)
Issued 2012, updated 2015
5
Key aspects covered by the guidelines
The key points from each guideline are listed on slides 7-20;
they cover the following aspects of diabetes and CKD:
• Testing for kidney disease
• When to suspect non-diabetic
renal disease
• Acute kidney injury
• Therapeutic interventions
• Therapeutic targets
• Referral advice
• Reviews and monitoring
• Auditing
6
NICE CG87 type 2 diabetes guidelines issued 2009,
modified December 2014 (slide 1 of 3)
Testing for kidney disease:
• First-pass morning urine specimen to be tested once a year for ACR testing1
• Measure serum creatinine and eGFR annually at the time of ACR testing1
• Discuss the significance of finding an abnormal ACR, and its trend over time,
with the individual concerned1
eGFR = estimated glomerular filtration rate
ACR = albumin creatinine ratio
NB: ACR is an important indicator of cardiovascular risk and progression.
Reference:
1. NICE clinical guideline 87. The management of type 2 diabetes. Issued: May 2009 last modified: December 2014.
7
NICE CG87 type 2 diabetes guidelines issued 2009,
modified December 2014 (slide 2 of 3)
Therapeutic interventions:
• Start ACE inhibitors with the usual precautions and titrate to full dose in all
individuals with confirmed raised ACR1
• Have an informed discussion before starting an ACE inhibitor in a woman for
whom there is a possibility of pregnancy, assessing the relative risks and
benefits of the use of the ACE inhibitor1
• Use an ARB instead of an ACE inhibitor for a person with an abnormal ACR if
an ACE inhibitor is poorly tolerated1
Therapeutic targets:
• For a person with an abnormal ACR, maintain blood pressure below
130/80 mmHg1
Referral advice:
• Agree referral criteria for specialist renal care between local diabetes
specialists and nephrologists1
Reference:
1. NICE clinical guideline 87. The management of type 2 diabetes. Issued: May 2009 last modified: July 2014.
8
NICE CG87 type 2 diabetes guidelines issued 2009,
modified December 2014 (slide 3 of 3)
When to suspect non-diabetic kidney disease:
• Suspect renal disease other than diabetic nephropathy and consider further
investigation or referral when the ACR is raised and ANY of the following
apply:1
– There is no significant or progressive retinopathy1
– Blood pressure is particularly high or resistant to treatment1
– The person previously had a documented normal ACR and develops heavy proteinuria
(ACR > 100 mg/mmol) 1
– Significant haematuria is present1
– The glomerular filtration rate has worsened rapidly1
– The person is systemically ill1
Reference:
1. NICE clinical guideline 87. The management of type 2 diabetes. Issued: May 2009 last modified: July 2014.
9
NICE CG182 CKD guidelines issued July 2014
(slide 1 of 4)
Testing for kidney disease:1
• Offer testing for CKD to people with any of the following risk factors:
– Diabetes
– Hypertension
– Acute kidney injury
– Cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral
vascular disease or cerebral vascular disease)
– Structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
– Multisystem diseases with potential kidney involvement – e.g. systemic lupus
erythematosus
– Family history of end-stage kidney disease or hereditary kidney disease
– Opportunistic detection of haematuria
Reference:
1. NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014.
10
NICE CG182 CKD guidelines issued July 2014
(slide 2 of 4)
Testing for kidney disease:
• Initial testing to identify CKD should include eGFR and ACR1
Therapeutic targets:
• Blood pressure should be maintained to target
– CKD with ACR <70 mg/mmol and no diabetes – target of 120-139/90 mmHg1
– CKD with ACR >70 mg/mmol, or diabetes – target of 120-129/80 mmHg1
Reference:
1. NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014.
11
NICE CG182 CKD guidelines issued July 2014
(slide 3 of 4)
•
•
Agree the frequency of monitoring
(eGFRcreatinine and ACR) with the person
with, or at risk of, CKD; bear in mind that CKD
is not progressive in many people1
Use the table shown to guide the frequency of
GFR monitoring for people with, or at risk of
CKD1
The frequency of monitoring should be tailored
to the individual, according to:
– The underlying cause of
CKD1
– Past patterns of eGFR and ACR1
– Comorbidities1
– Changes to their treatment1
– Intercurrent illness1
– Whether they have chosen conservative
management of CKD1
ACR categories (mg/mmol),
description and range
A1 <3
Normal to
mildly
increased
A2 3-30
Moderately
increased
A3 >30
Severely
increased
G1 >90
Normal and high
<1
1
>1
G2 60-89
Mild reduction
related to normal
range for a
young adult
<1
1
>1
G3a 45-59
Mild-moderate
reduction
1
1
2
G3b 30-44
Moderate-severe
reduction
<2
2
>2
G4 15-29
Severe reduction
2
2
3
G5 <15
Kidney failure
4
>4
>4
Increasing risk
•
GFR categories (ml/min/1.73 m2), description and range
Reviews and monitoring:
The numbers in this
table indicate
recommended
frequency of
monitoring per year
Increasing risk
Adapted from: NICE clinical guideline 182. Chronic kidney disease early identification and
management of chronic kidney disease in adults in primary and secondary care. July 2014.
Reference:
1. NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014.
12
NICE CG182 CKD guidelines issued July 2014
(slide 4 of 4)
Testing and monitoring for kidney disease:
• Creatinine-based eGFR can give a misleading result1
– In certain circumstances a cystatin C test may help to confirm or refute a CKD
diagnosis made with a creatinine-based eGFR1
• Consider using cystatin C-based eGFR at initial diagnosis to confirm or rule out
CKD in people with:
– An eGFR of 45–59 mL/min/1.73m2, sustained for at least 90 days and1
– No proteinuria (ACR less than 3 mg/mmol) or other marker of kidney disease1
• Slide 14 provides a summary of the key differences between creatinine-based
eGFR and cystatin C-based eGFR
• Do not diagnose CKD in people with:
– An eGFR (estimated using serum creatinine) of 45–59 mL/min/1.73m2 and1
– An eGFR (estimated using cystatin C) of more than 60 mL/min/1.73m2 and1
– No other marker of kidney disease1
Reference:
1. NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014.
13
A comparison of estimating GFR using cystatin C
versus creatinine based tests
Cystatin C to estimate GFR
Creatinine to estimate GFR
Produced by all nucleated cells1
Produced by muscle cells1
Almost 100% reabsorbed by the tubules and is
undetectable in normal urine1
100% filtered at the glomerulus with some
tubular reabsorption1
Blood level independent of muscle mass or
diet1
Blood level depends on muscle mass and
is also affected by meat content of diet1
Blood level is falsely raised in hypothyroidism
and lowered in hyperthyroidism1
Unaffected by thyroid activity1
May be increased by inflammation2
–
Assay costs approximately £2.50*1
Assay costs approximately £0.25*1
*Prices are quoted according to 2015 figures
Reference:
1. Lewis R. Updated NICE guidelines for the diagnosis and management of chronic kidney disease: what they mean for your practice. Article to be submitted to Primary Care
Cardiovascular Journal.
2. Singh D et al. Nephrology Dialysis Transplantation 2007;22:1087–1092.
14
Acute kidney injury: NICE CG182 CKD guidelines
issued July 2014
Acute kidney injury:
Guideline 182 recommends:
• Monitor people for the development or progression of CKD for at least 2-3
years after acute kidney injury, even if serum creatinine has returned to
baseline1
• Advise people who have had acute kidney injury that they are at increased
risk of CKD developing or progressing1
• In people with a new finding of reduced GFR, repeat the GFR within 2 weeks
to exclude causes of acute deterioration of GFR – for example, acute kidney
injury1
Reference:
1. NICE clinical guideline 182. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care. July 2014.
15
NICE CG169 acute kidney injury guidelines issued
August 2013
Acute kidney injury:
• Investigate for acute kidney injury, by measuring serum creatinine and
comparing with baseline, in adults with acute illness if diabetes is likely
or present1
• Before offering iodinated contrast agents to adults for emergency or
non-emergency imaging, assess their risk of acute kidney injury1
– Be aware that increased risk of acute kidney injury is associated with diabetes, but
only with chronic kidney disease1
– Adults with an eGFR less than 40 mL/min/1.73m2 are at particular risk1
• Assess the risk of acute kidney injury in adults before surgery1
– Be aware that increased risk is associated with diabetes1
Reference:
1. NICE clinical guideline 169. Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy. August 2013.
16
UK Renal Association CKD guidelines 5th Edition,
2009-2011 (slide 1 of 2)
Therapeutic targets:
• For people with CKD and diabetes, the systolic blood pressure should be
lowered to <130 mmHg (target range 120-129 mmHg) and diastolic blood
pressure should be <80 mmHg, unless the risks are considered to outweigh the
potential benefits1
Therapeutic intervention:
• Antihypertensive therapy should be individualised and lowering the systolic
blood pressure to <120 mmHg should be avoided1
• Patients with diabetes and albuminuria should be treated with an ACE inhibitor
(ACEI) or ARB, titrated to maximum licensed antihypertensive dose if tolerated,
regardless of the initial blood pressure, unless these drugs are specifically
contraindicated1
• People with diabetes and CKD should achieve ‘good glycaemic control’1
Reference:
1. UK Renal Association. Clinical Practice Guidelines. Detection, Monitoring and Care of Patients with CKD. 5th Edition, 2009-2011. Final Version (28.02.2011).
17
UK Renal Association CKD guidelines 5th Edition,
2009-2011 (slide 2 of 2)
Auditing:
• Possible audit measures for detection, monitoring and care of CKD include:
– Proportion of patients with diabetes and albuminuria (without specific
contraindications) who had an ACEI or ARB on their last recorded list of chronic
medications1
– Proportion of patients receiving an ACEI or ARB for diabetes and albuminuria who
received the maximum licensed antihypertensive dose (or maximum dose tolerated
without hypotension) on their most recent prescription1
– Proportion of patients with diabetic kidney disease and follow-up for at least six
months, whose last recorded HbA1c was below their agreed target1
– Average HbA1c of all patients with diabetes and CKD1
Screening: There is high quality evidence on the economic case for screening for CKD in
patients with diabetes1
Early intervention: As loss of renal function in CKD is generally irreversible, it is assumed
that early intervention is of more benefit. The precise stage at which intervention becomes
worthwhile is not well-defined except for diabetes1
Reference:
1. UK Renal Association. Clinical Practice Guidelines. Detection, Monitoring and Care of Patients with CKD. 5th Edition, 2009-2011. Final Version (28.02.2011).
18
ADA/EASD position statement issued 2012, updated
2015 (slide 1 of 2)
• In 2012, the American Diabetes Association (ADA) and European Association for the
Study of Diabetes (EASD) published a position statement on the management of
hyperglycaemia in non-pregnant adult patients with type 2 diabetes1,2
– This was needed because of an increasing array of antihyperglycemic drugs and growing
uncertainty regarding their proper selection and sequence3
The key points from the initial recommendations were as follows:
• Glycaemic targets and glucose-lowering therapies must be individualised1
• Diet, exercise and education remain the foundation of any treatment programme1
• Unless there are prevalent contraindications, metformin is the optimal first-line drug1
• After metformin, combination therapy with an additional 1-2 oral or injectable agents is
reasonable1
• Many patients will require insulin therapy alone or in combination with other agents1
• All treatment decisions, where possible, should be made in conjunction with the patient1
• Comprehensive cardiovascular risk reduction must be a major focus of therapy1
References:
1. Inzucchi SE, et al. Diabetes Care 2012;35:1364–1379. 2. Inzucchi SE et al. Diabetologia 2012;55:1577–1596. 3. Inzucchi SE et al. Diabetes Care 2015;38:140–149.
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ADA/EASD position statement issued 2012, updated
2015 (slide 2 of 2)
• In 2015, the position statement was updated and the following information on glucose
lowering agents was included:
The 2015 update
“…there are now more head-to-head trials that show slight variance between agents with regard to
glucose-lowering effects.”1
Key points from the 2015 update:
• The major change in treatment options has been the availability of a new class of glucoselowering drugs, the sodium–glucose co-transporter 2 (SGLT2) inhibitors, which reduce
HbA1c by 0.5-1.0% (5.5-11 mmol/mol) vs. placebo1
• While the SGLT2 inhibitors are approved as monotherapy, they are mainly used in
combination with metformin and/or other agents; given their demonstrated efficacy and
clinical experience to date, they are reasonable options as second-line or third-line agents1
• Earlier concerns that the thiazolidinediones are associated with bladder cancer have
largely been allayed by subsequent evidence1
• In patients where glucose control remains poor despite the use of three antihyperglycemic
drugs in combination, the effectiveness of combining GLP-1 receptor agonists with basal
insulin has been demonstrated1
References:
1. Inzucchi SE et al. Diabetes Care 2015;38:140–149.
20
NICE Quality Standard for Diabetes QS6 (slide 1 of 2)
Statement 1. People with diabetes and/or their carers receive a structured educational programme that
fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing
education.1
Statement 2. People with diabetes receive personalised advice on nutrition and physical activity from an
appropriately trained healthcare professional or as part of a structured educational programme.1
Statement 3. People with diabetes participate in annual care planning which leads to
documented agreed goals and an action plan.1
Statement 4. People with diabetes agree with their healthcare professional a documented personalised
HbA1c target, usually between 48 mmol/mol and 58 mmol/mol (6.5% and 7.5%), and receive an ongoing
review of treatment to minimise hypoglycaemia.1
Statement 5. People with diabetes agree with their healthcare professional to start, review and stop
medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance.1
Statement 6. Trained healthcare professionals initiate and manage therapy with insulin within a structured
programme that includes dose titration by the person with diabetes.1
Statement 7. Women of childbearing age with diabetes are regularly informed of the benefits of
preconception glycaemic control and of any risks, including medication that may harm an unborn child.
Women with diabetes planning a pregnancy are offered preconception care and those not planning a
pregnancy are offered advice on contraception.1
Reference:
1. NICE quality standard 6. Diabetes in adults quality standard. Issued: March 2011.
21
NICE Quality Standard for Diabetes QS6 (slide 1 of 2)
Statement 8. People with diabetes receive an annual assessment for the risk and presence of the
complications of diabetes, and these are managed appropriately.1
Statement 9. People with diabetes are assessed for psychological problems, which are then managed
appropriately.1
Statement 10. People with diabetes at risk of foot ulceration receive regular review by a foot protection
team in accordance with NICE guidance.1
Statement 11. People with diabetes with a foot problem requiring urgent medical attention are referred to
and treated by a multidisciplinary foot care team within 24 hours.1
Statement 12. People with diabetes admitted to hospital are cared for by appropriately trained staff,
provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing
their own insulin.1
Statement 13. People admitted to hospital with diabetic ketoacidosis receive educational and
psychological support prior to discharge and are followed up by a specialist diabetes team.1
Statement 14. People with diabetes who have experienced hypoglycaemia requiring medical attention
are referred to a specialist diabetes team.1
Reference:
1. NICE quality standard 6. Diabetes in adults quality standard. Issued: March 2011.
22
NICE Quality Standard for CKD QS5
Statement 1. People with risk factors for CKD are offered testing, and people with CKD are correctly identified.1
Statement 2. People with CKD who may benefit from specialist care are referred for specialist assessment in
accordance with NICE guidance.1
Statement 3. People with CKD have a current agreed care plan appropriate to the stage and rate of progression
of CKD.1
Statement 4. People with CKD are assessed for cardiovascular risk.1
Statement 5. People with higher levels of proteinuria, and people with diabetes and microalbuminuria, are
enabled to safely maintain their systolic blood pressure within a target range 120–129 mmHg and their diastolic
blood pressure below 80 mmHg.1
Statement 6. People with CKD are assessed for disease progression.1
Statement 7. People with CKD who become acutely unwell have their medication reviewed, and receive an
assessment of volume status and renal function.1
Statement 8. People with anaemia of CKD have access to and receive anaemia treatment in accordance with
NICE guidance.1
Statement 9. People with progressive CKD whose eGFR is less than 20 mL/min/1.73m2, and/or who are likely to
progress to established kidney failure within 12 months, receive unbiased personalised information on
established kidney failure and renal replacement therapy options.1
Statement 10. People with established renal failure have access to psychosocial support (which may include
support with personal, family, financial, employment and/or social needs) appropriate to their circumstances.1
Reference:
1. NICE quality standard 5. Chronic kidney disease. Issued: March 2011 last modified: November 2014.
23
QOF: CKD indicator for 2015-16
As of April 2015 the QOF in England will include the following indicator:
Indicator
CKD 1: The contractor establishes and maintains a register of patients aged 18 or over with
CKD Stage 3 to 51
Points
6
Note: CKD is no longer included in the QOF for Wales
Reference:
1. NHS employers. Summary of changes to QOF 2015/16 – England. Available at: http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/
QOF/QOF% 20Home%20Page/ 2015-16%20Summary%20of%20changes%20to%20QOF.pdf. Website last accessed 15.01.15.
24
QOF: Diabetes indicators for 2015-16 (slide 1 of 2)
Indicator
Points
DM017: The contractor establishes and maintains a register of all patients aged 17 or over
with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been
confirmed1
6
DM002: The percentage of patients with diabetes, on the register, in whom the last blood
pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less1
8
DM003: The percentage of patients with diabetes, on the register, in whom the last blood
pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less1
10
DM004: The percentage of patients with diabetes, on the register, whose last measured total
cholesterol (measured within the preceding 12 months) is 5 mmol/l or less1
6
DM006: The percentage of patients with diabetes, on the register, with a diagnosis of
nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with ACE-I
(or ARBs) 1
3
DM007: The percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c is 59 mmol/mol or less in the preceding 12 months1
17
DM008: The percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c is 64 mmol/mol or less in the preceding 12 months1
8
Reference:
1. NHS employers. Summary of changes to QOF 2015/16 – England. Available at: http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/
QOF/QOF% 20Home%20Page/ 2015-16%20Summary%20of%20changes%20to%20QOF.pdf. Website last accessed 15.01.15.
25
QOF: Diabetes indicators for 2015-16 (slide 2 of 2)
Indicator
Points
DM009: The percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c is 75 mmol/mol or less in the preceding 12 months1
10
DM018: The percentage of patients with diabetes, on the register, who have had influenza
immunisation in the preceding 1 August to 31 March1
3
DM012: The percentage of patients with diabetes, on the register, with a record of a foot
examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2)
increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus
deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 12
months1
4
DM014: The percentage of patients newly diagnosed with diabetes, on the register, in the
preceding 1 April to 31 March who have a record of being referred to a structured education
programme within 9 months after entry on to the diabetes register1
11
Reference:
1. NHS employers. Summary of changes to QOF 2015/16 – England. Available at: http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/
QOF/QOF% 20Home%20Page/ 2015-16%20Summary%20of%20changes%20to%20QOF.pdf. Website last accessed 15.01.15.
26
National CKD Audit
• The National Chronic Kidney Disease Audit will audit the care of all eligible
people over 18 years with CKD1
• This important 3-year project focuses on the diagnosis and management of
people with CKD in primary care to:
1. Improve the identification of CKD patients in primary care1
2. Improve the management and outcomes of CKD patients1
3. Tailor the care of people with CKD to local care pathways1
• Regular audit reports and Quality Improvement Tools will support in running the
audit1
• It was commissioned by the Healthcare Quality Improvement Partnership
(HQIP), and funded by NHS England1
• A pilot stage, involving 440 GP
practices. The full audit
will then commence in early 20151
Reference:
1. National Kidney Chronic Kidney Disease Audit. Available at: http://www.ckdaudit.org.uk. Website last accessed 15.01.15
27
National Diabetes Audit
• The following data show the percentages of patients
with type 2 diabetes recorded against criteria in the
2012-13 National Diabetes Audit
• NICE-recommended care processes
– Completion of eight care processes (all care processes
except eye screening) = 61.9%1
– Completion was less likely to be achieved by those aged
under 40 vs. older people1
• NICE-recommended treatment targets
NICE-recommended care
processes (annual checks)1
1. HbA1c
2. Blood pressure
3. Cholesterol
4. Serum creatinine
5. Urine albumin
– Glucose control (HbA1c <58mmol/mol) = 64.8%1
6. Foot surveillance
– Blood pressure (<140/80) = 68.7%1
7. BMI
– Serum cholesterol <4 mmol/L = 40.5%1
8. Smoking
• NICE-recommended structured education*
– Offered structured education = 16.7% of newly diagnosed;
6% of all people with type 2 diabetes1
– Attended structured education = 3.6% of newly diagnosed;
1.6% of all people with type 2 diabetes1
9. Eye screening
*NICE guidance recommends that
people with diabetes be offered patient
education programmes, officially known
as 'structured education‘1
Reference:
1. Health and Social Care Information Centre, National Diabetes Audit 2012-2013 Report 1: Care Processes and Treatment Targets. Available at:
http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2014-15/NDA-Care-Processes-report-1-Final.pdf Website last accessed on 09.01.15
28
Summary of guidance, standards and indicators to
consider in patients with diabetes and CKD
Diabetes
CKD
NICE CG87
NICE CG182
UK Renal Association
Guidelines
NICE QS6
NICE CG169
QOF CKD
Indicator
ADA/EASD
Position Statement
NICE QS5
National CKD
Audit
QOF Diabetes
Indicators
National Diabetes
Audit
29
Section I – summary
• ACR and eGFR should be measured annually in people with diabetes
• Diabetic kidney disease should be monitored with increasing frequency as
disease progresses, in line with NICE guidelines
• Early intervention is key to improving prognosis
• Blood pressure should be managed with ACE inhibitors or ARBs first line
(unless contraindicated)
• In people with diabetes and proteinuria, ACE inhibitors and ARBs should be
used even if patients are normotensive (unless contraindicated)
• Treatment of people with diabetes and CKD should be informed by the
guidelines, but individualised accordingly
• Agree a referral procedure within your own network/locality
• It is important to audit best practice in addition to QOF measures
30