2408
Is diabetic care for haemodialysis patients optimum? Room for improvement
Forbes SH, Redington K, Olaitan A, Kumaralingam P, Yaqoob M M
Department of Renal Medicine and Transplantation, Royal London Hospital, Whitechapel
Introduction: Diabetic end-stage renal disease (DESRD) is the leading cause for renal replacement therapy. Patients with DESRD carry considerable cardiovascular co-morbidities and are at increased risk of potentially preventable blindness and amputations. It is generally assumed that DESRD patients continue to have their diabetic care co-ordinated in their existing diabetic clinics, eithercommunity or hospital based. We set out to assess whether, under this assumption,DESRD patients continue to receive optimal diabetic care.
Methods: We reviewed all prevalent hospital-based haemodialysis patients in our renal unit (n=373) to establish the prevalence of DESRD. We used theNICE quality standard guidelines for diabetes in adults to assess the diabetic care our patients, encompassing HbA1c measurement, frequency of hypoglycaemic episodes, retinopathy and screening, peripheral neuropathy and access to foot care. We gathered demographic data on all patients, including smoking status.
Results: We found that 31% (n=114) of patients were diabetic. Of those, the overwhelming majority were type 2 (96%) with the remaining 4% either type 1 or new-onset diabetes after transplantation (NODAT). 60% of diabetic patients were male and more than half (56%) were Asian. Median duration of diabetes was 19 years and diabetes (alone or combined with hypertension) was the cause of ESRD in 85% of patients. The majority of patients were on insulin therapy (67%) with 5% receiving insulin and oral therapies, 16% oral therapy, and 12% diet alone. Median weight was 69kg. 64% were dialysing via an arterio-venous fistula and 19% were active on the transplant list.
In terms of diabetic control and complications, we found that 73% of patients were monitored by their GP with the remainder either in a hospital clinic (22%) or unsure if they were being monitored (5%). Control was generally poor; 20% had an HbA1C within the target 48-58mmol/L. Median length of time from last HbA1c was 104 days (range 31 days – 9.5 years). Just under half of patients reported frequent episodes of symptomatic hypoglycaemia, around half of whom reported an episode at least monthly.
11% were smokers and all had been offered smoking cessation. 69% had cholesterol less than 4mmol. 25% met the recommended BP target of <130/80 pre-dialysis and 34% post-dialysis.Retinopathy was common with 74% having established diabetic retinopathy. 80% of patients had screening within the last year. Neuropathy was less common with 36% having symptoms and 5% had Charcot joints. Of the patients identified, 8% had previously had an amputation (including toes, metatarsal head, and below-knee amputations). Overall only 60% had access to foot care.Many patients expressed they would value a diabetic liaison service whilst on dialysis, with medication review and foot review being performed during their time on HD.
Conclusion: Against the standards set out by NICE, our diabetic dialysis patients had acceptable care with regards to smoking cessation, cholesterol and retinopathy screening. The worrying frequency of hypoglycaemic episodes, and the small percentage with a target HbA1c was less encouraging. Furthermore, in light of the fact these arehigh risk patients, foot care should be more prominent. This data highlights the need for, and patient desire for,a more tailored care pathway for diabetic HD patients, ideally provided whist they are on dialysis, involving patient and carer education.