Wednesday, 16 June 2010

Diabetes week – remember the urine and the feet

The National Diabetes Audit Annual Report for Adults and Children was published today as part of Diabetes Week which is promoted by Diabetes UK. The NDA report makes uncomfortable reading, as Douglas Smallwood (CEO at Diabetes UK) said. Only 50% of adults with Type 2 diabetes, 32% of adults with Type 1 diabetes and 5%, that’s 1 in 20, children and young people had all the 9 care processes by the National Institute for Health and Clinical Excellence (NICE) recorded. Care is improving from a low of about 10% of adults receiving all 9 care processes 6 years ago but the testing for proteinuria by measuring urinary albumin creatinine ratio is still the lowest at 68% in Type 2 diabetes and 51% in Type 1 diabetes. By contrast blood pressure measurement remains the most frequently recorded process at 96% and 89% respectively. Dr Rowan Hillson (National Clinical Director for Diabetes) commented “no urine test means no detection of micro albuminurea and missed opportunities to prevent a progressive diabetic kidney injury in turn leading to more people suffering the consequences of chronic kidney disease – premature vascular disease and development of end stage renal disease”. The NDA report says end stage renal failure has increased from 0.78% in 2003-4 to 1.27% in 2008-9; the corresponding figures for Type 2 diabetes are 0.26% and 0.48%. Some of this is likely to be due to better recording and ascertainment now that colleagues in primary care are more involved in kidney management. Looking at the Renal Registry data it looks like there’s been a 16% increased in ESRD due to diabetes over the last decade with a flat incidence rate over the last 3 years at 22 patients pmp.

There’s a real opportunity to get the NDA, which is the world’s largest such audit, and the UK Renal Registry, the only totally electronic and comprehensive ESRD audit in the world, to work together to further increase the power of both these clinical audits. The aims of both are of course to “close the loop” and help drive up improvements in care. The variance in diabetes care at GP, primary care trust and renal unit level are strong pointers that local quality improvement approaches can result in considerable benefit for people with kidney disease as a result of diabetes.

Foot ulceration is another area that recently caught my eye. Andrew Boulton (Professor of Medicine and Diabetes at the Manchester Academic Health Science Centre) with Anand Vardhan and Ashwindbhai Asari (Manchester Royal Infirmary) and other colleagues, have recently reported that dialysis is independently associated with foot ulceration. Those of us that venture onto dialysis units are well aware of the number of people with amputations and the added difficulties that causes to patients and families. The authors note “our findings have important clinical implications as they alert healthcare practitioners that dialysis is an independent risk factor for foot ulceration thus requiring extra vigilance and foot care”. They also point out that “current diabetes guidelines and recommendations fail to recognise the strength of the link between dialysis treatment and foot ulceration. Our findings suggest that in terms of foot ulcer risk, dialysis should be ranked equivalent to a history of previous foot ulceration (ie a risk category 3, [International Working Group on the Diabetic Foot] classification [risk 0 (no risk factors), risk 1 9neuropathy and no other risk factors), risk 2 (PAD with/without neuropathy), risk 3 (current foot ulcer, history of foot ulcer or amputation), and risk 4 (current foot ulcer, history of foot ulcer, or prior amputation)])”.

Diabetic kidney disease was the topic of World Kidney Day 2010 . With the 2 most powerful audits in diabetes and end stage renal failure in the world there is real opportunity for joint working in the community, in hospital and dialysis care and nationally.