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Joint endocrinologist-nephrologist clinic reduced diabetic kidney disease progression
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Patients with type 2 diabetes and stage 3 or 4 chronic kidney disease who attended a joint endocrinologist-nephrologist diabetic kidney disease clinic were less likely to progress to end-stage renal disease after 3 years vs. similar patients seen at a diabetes center, according to findings from a nested, case-control study.
“Studies have looked into referrals for nephrology care or multidisciplinary care in an effort to improve renal outcomes with chronic kidney disease,” Serena Low, MBBS, a consultant in the clinical research unit at Khoo Teck Puat Hospital, Singapore, and colleagues wrote. “These [studies] suggest that service dedicated to renal care may be associated with better outcomes. Hitherto, there is no study that examines the impact of a renal management clinic on renal progression in patients with [type 2 diabetes].”
Low and colleagues analyzed data from patients with type 2 diabetes and CKD at stage 3 or 4, seen prospectively at a secondary care diabetes center in Singapore (mean age, 49 years; 53.4% men; 67.3% ethnic Chinese; mean diabetes duration, 15.1 years; 23.4% with obesity). Patients referred by the diabetes center to a CKD clinic between November 2001 and April 2015 were considered cases (n = 418); controls were patients with the same baseline characteristics but not referred to the clinic (n = 419). In the CKD clinic, six diabetic kidney disease sessions were conducted monthly, led by a senior consultant nephrologist and endocrinologist, providing joint-consult, in-person patient care. The clinic was supported by a broader care team of advanced practice nurses, clinical pharmacists, dietitians and social workers who reinforced lifestyle management plans. Additionally, monthly staff education sessions were organized to facilitate cohesion of the multi-disciplinary team.
The primary outcome was occurrence of stage 5 CKD, defined as an estimated glomerular filtration rate of 15 mL/min/1.73 m² or less. Secondary outcomes included changes from baseline in HbA1c, blood pressure, LDL cholesterol and urinary albumin-to-creatinine ratio. Researchers used linear mixed models incorporating within-patient variation, between-patient variation and the correlation structure of repeated measurements to compare outcomes of the CKD clinic participants with non-CKD clinic participants.
During a mean follow-up of 3 years, 240 patients reached stage 5 CKD, including 45.8% from the CKD clinic group and 54.2% from the non-clinic group. Patients who progressed to stage 5 tended to have a younger age of disease onset and worse metabolic profile, and were less likely to use a renin-angiotensin system (RAS) antagonist vs. those who did not progress to stage 5 (P = .006).
In Cox regression analysis, researchers found that patients who were referred to the CKD clinic were 45% less likely to progress to stage 5 CKD vs. those who were not referred (95% CI, 0.36-0.83). In linear mixed models, patients referred to the CKD clinic also achieved a lower HbA1c (beta = –0.28; P = .036), diastolic BP (beta = –43.91; P < .001) and log-transferred urinary albumin-to-creatinine ratio (beta = –0.39; P = .006) compared with those who were not referred to clinic. There were no between-group differences for systolic BP or LDL cholesterol, according to researchers.
The researchers noted that there was a higher percentage of patients prescribed RAS antagonists in the CKD clinic group vs. those not referred to clinic (79.7% vs. 71.6%), which could reflect more intensive treatment received in the clinic group. Additionally, a higher percentage of patients who did not develop stage 5 CKD were using RAS antagonists compared with those who did not develop stage 5 CKD (78.2% vs. 69.2%). However, any association between RAS antagonists and occurrence of stage 5 CKD lost significance in Cox regression models.
“‘Reverse causation’ may also account for the fact that patients with higher renal burden may have intolerance to the use of RAS antagonist for reasons like hyperkalemia or excessive deterioration in eGFR upon initiation of RAS blockade,” the researchers wrote. “However, we lack high-resolution information on duration, dosage and compliance with RAS-antagonist. Future studies need to take such information into account in examining the impact of nephrology care on CKD progression. Nevertheless, our findings may inform future management strategies targeted at patients with [type 2 diabetes] and CKD, especially with regard to joint specialist management involving an endocrinologist and nephrologist.” – by Regina Schaffer
Disclosures: The authors report no relevant financial disclosures.
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