SECTION 4:

Implications for routine review of patients with type 2 diabetes

Treated suboptimally, type 2 diabetes can have devastating complications, including cardiovascular disease, kidney disease and sight loss.1 A crucial part of diabetes care is the clinical review, which everyone with type 2 diabetes should undergo at least annually.1

Diabetes UK (DUK) has reinforced the need for annual screening for kidney disease and function for everyone with diabetes, which should include both a blood test for serum creatinine and calculation of eGFR, and a urine test for albumin excretion. However, urine testing for albumin remains the least frequently completed care process in diabetes.2

The National Diabetes Audit (NDA) showed that, in 2017-18, 4 in 10 people with type 2 diabetes did not receive all the recommended health checks.*3

TABLE 1. PERCENTAGE OF PEOPLE WITH DIABETES RECEIVING RECOMMENDED HEALTHCARE CHECKS IN 2017-183

Healthcare check completed Type 1 Type 2
All 8 healthcare checks* 42% 58%
HbA1c 85% 95%
Blood pressure 91% 96%
Cholesterol 80% 93%
Kidney function 83% 95%
Urinary albumin 51% 66%
Foot exam 74% 86%
Body mass index (BMI) 82% 95%
Smoking review 90% 95%
Improved since 2012-13; Deterioriated since 2012-13; Remained the same

*The NDA is unable to collect data on eye screening so the report covers eight of the nine recommended health checks

In terms of kidney function, NICE recommends that monitoring should take place more frequently (Figure 3) for patients with or at risk of CKD, i.e. people with:

  • Diabetes
  • Hypertension
  • Acute kidney injury
  • Cardiovascular 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 (GFR category G5) or hereditary kidney disease
  • Opportunistic, detection of Haematuria4

Figure 3. RECOMMENDATIONS FOR FOLLOW-UP BASED ON GFR AND ACR CATEGORY2

Guide to frequency of monitoring (times per year) by GFR and albuminuria category Persistent albuminuria categories
Description and range
A1 A2 A3
Normal to mildly increased Moderately increased Severely increased
<30mg/g
<3mg/mmol
30-300mg/g
3-30mg/mmol
>300mg/g
>30mg/mmol
G1 Normal or high ≥90 1 if CKD 1 2
G2 Mildly decreased 60-89 1 2
G3a Mildly to moderately decreased 45-59 1 2 3
G3b Moderately to severely decreased 30-44 2 3 3
G4 Severely decreased 15-29 3 3 4+
G5 Kidney failure <15 4+ 4+ 4+

Adapted from NICE CG1824

Each review should prompt the clinician to consider the patient’s current medication, and if and how it might need to be adjusted if renal function has changed. Reviews should include lifestyle advice such as smoking cessation, weight management and encouragement to follow a healthy eating and physical activity programme.5

Job code: UK/DIA-19020d DOP: June 2020

References

  1. Milne N, Di Rosa F. The diabetes review: a guide to the basics. J Diabetes Nursing 2019;23(1):1-8
  2. Diabetes UK. Preventing kidney failure in people with diabetes: Position statement; August 2016. https://www.diabetes.org.uk/professionals/position-statements-reports/specialist-care-for-children-and-adults-and-complications/preventing-kidney-failure-in-people-with-diabetes [Accessed June 2020]
  3. NHS Digital. National Diabetes Audit, 2017-18. Report 1: Care processes and treatment targets; 2019. https://files.digital.nhs.uk/88/F1E544/National%20Diabetes%20Audit%202017-18%20Full%20Report%201%2C%20Care%20Processes%20and%20Treatment%20Targets.pdf [Accessed June 2020]
  4. NICE CG182. Chronic kidney disease in adults: assessment and management; July 2014 (Updated January 2015). https://www.nice.org.uk/guidance/cg182 [Accessed June 2020]
  5. Bostock-Cox B. Prescribing in renal impairment. Practice Nurse 2019;49(3):33-37