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Diabetes prevalence, glycaemic control and management inhaemodialysis patients
Creme, D. and McCafferty, K.
Royal London Hospital, Barts Health NHS Trust, London
Introduction/Aims: Diabetic nephropathy is the main cause of end stage renal failure (ESRF) and renal replacement therapy (RRT). Targets for therapy once haemodialysis (HD) is initiated are unclear and currently based on inaccurate tests. This report attempts to identify the number of diabetic patients receiving HD in a large London NHS Trust, their current glycaemic control, impact on other outcomes, current management, responsibility of care and the challenges faced.
Methods:All adult patients currently receiving HD in the Trust were identified from an electronic patient management software system.Diabetic patients were identified from the problem and medication list recorded. Most recent HbA1c recorded was used as a marker for glycaemic control. Patients without diabetes identified or without an HbA1c result were excluded from the biochemical analysis. Biochemistry was identified at the time of the most recent HbA1c. IDWG were analysed from weights recorded pre and post dialysis 2 weeks pre and post most recent HbA1c date. Correlations were calculated using GraphPad Prism 6 Mac OS.HbA1c was further adjusted for albumin (Alb) and haemoglobin (Hb) based on published data. Sub analysis took the form of interviews with patients about self-management and with their GP surgeries regarding frequency of reviews, policy and responsibility of care.
Results: Total HD patients, n=979; diabetic HD patients n=412; HbA1c risk categories: At risk (<36mmol/mol) = 8%, Good control (37-63mmol/mol) =57%, At risk (64-85mmol/mol) =24%, At high risk (>86mmol/mol)=7%. HbA1c adjusted for Alb and Hb resulted in a higher number of patients with poor glycaemic control (39% vs 55%). Significant positive correlations were found with IDWG (p<0.02, r=0.14) and pre dialysis bicarbonate (p<0.02, r=0.12), and a negative association with pre dialysis sodium (p<0.0001, r=-1.9). A weak but non-significant association was found with CRP and Alb (p=0.07 and p=0.08 respectively). No association was found with Hb, ferritin, TSAT, WCC, PTH, K and vitamin D. A larger number of patients with diabetes had amputations (24 vs 2) with 46% having an HbA1c >65mmol/mol.
Sub analysis (n=10). 80% were on long term insulin therapy but only 38% self-adjusted. Majority (60%) did not perform regular blood glucose monitoring (< once/wk) and half experienced late (<3mmol/l) hypoglycaemia awareness. While the majority of GPs (90%) reported responsibility of care lay with them and had annual reviews as a minimum, 40% of patients had not been seen in the past 12 months.
Conclusion: Large number of diabetic patients on HD have poor glycaemic control. This may lead to higher IDWG, larger sodium and bicarbonate shifts, increased number of amputations and possibly increased inflammation and decreased nutritional status. All these factors result in worst outcomes and poor QoL for these patients. Self care is poor and frequency of clinical reviews are inadequate. Comprehensive guidelines and more accurate long term tests for glycaemic control are needed. Physiological, behavioural and organisational factors influence the ability to achieve good glycaemic control. A centralised multidisciplinary team approach including Nephrologists, Diabetologists, specialist renal/diabetes nurses and specialist renal/diabetes dietitians may be more effective in achieving good glycaemic control.