SA JOURNAL OF DIABETES & VASCULAR DISEASE
ACHIEVING BEST PRACTICE
VOLUME 7 NUMBER 1 • MARCH 2010
23
Achieving blood pressure control in patients with
type 2 diabetes and diabetic renal disease by a
nurse-led protocol-based clinic
JULIE A MUGARZA,
1
JOHN P WILDING,
1
ANN WOODWARD,
1
KATHARINE HAYDEN,
2
GEOFFREY V GILL
1
Abstract
E
vidence-based management of type 2 diabetic
renal disease requires use of angiotensin
converting enzyme inhibitor (ACE inhibitor)
inhibitors or angiotensin receptor blockers (ARBs),
with strict blood pressure control which is difficult to
achieve in standard doctor-led diabetic clinics and we
have therefore developed a nurse-led clinic using a
therapeutic algorithm. ACE inhibitor or ARB treatment
was maximised, and antihypertensive drugs titrated
or added to optimise blood pressure control. Patients
were seen monthly until target blood pressure was
met, and then discharged for review of blood pressure
control 12 months later. Of 71 patients completing
the programme, 52 (72%) had microalbuminuria, and
19 (28%) nephropathy. ACE inhibitor or ARB usage
increased from 66 to 91% at review (
p
=
0.0004).
Systolic blood pressure fell from 152
±
21 to 131
±
18
mmHg (
p
<
0.0001) and diastolic blood pressure from
76
±
13 to 68
±
10 mmHg (
p
<
0.0001). Microalbuminuria
rates fell but estimated glomerular filtration rates
rose. Structured nurse-led clinics are useful in the
optimisation of treatment for type 2 diabetic patients
with renal disease.
Introduction
The prevalence of type 2 diabetes is globally increasing, and
renal disease, that is, microalbuminuria and nephropathy, is
a major complication of the condition. Strict control of BP
in type 2 diabetes reduces complications and mortality,
1
but
is particularly important in retarding progression of renal
disease.
2
Specific use of the ARB irbesartan has been shown
to reduce progression of microalbuminuria to nephropathy
in type 2 diabetes,
3
and also to slow the progression of
established nephropathy.
4
This effect of ARB drugs appears to
be shared with ACE inhibitors.
5
Despite the proven efficiency
of strict BP control and ACE inhibitor or ARB usage, audit data
show that these drugs are not universally used in diabetic
renal disease, and that BP control is frequently sub-optimal.
6
Evidence-based treatment strategies support tight BP control
(
<
130/80 mmHg) and use of drugs which block the renin–
angiotensin system. These strategies are also included in the
United Kingdom National Service Framework for Diabetes
and other national and international guidelines.
7–11
In type 2 diabetes with hypertension but without renal
complications, we have shown that when patients are seen
frequently in nurse-led clinics, using target-based algorithms
for drug treatment, the vast majority of patients can achieve
excellent BP control.
12
In this paper we describe our experience
using similar methods for a more complex group of patients
with microalbuminuria and nephropathy; aiming at even
stricter BP control and universal ACE inhibitor or ARB usage.
Materials and methods
Clinic organisation
Patients were referred consecutively from routine consultant
diabetic outpatient clinics at the Walton Diabetes Centre
(Aintree University Hospitals, Liverpool, UK). All had type
2 diabetes with either microalbuminuria or nephropathy
(Table 1), and the primary aim was to optimise BP
<
130/80
mmHg and to maximise ACE inhibitor and ARB use.
Statins and antiplatelet drugs were given if indicated.
Lifestyle issues were discussed and information given on local
smoking cessation and exercise for health schemes. The clinic
was managed by a registered nurse, with a nursing degree,
1
Department of Diabetes and Endocrinology, University of Liverpool,
Clinical Sciences Centre, Aintree University Hospitals, Liverpool, UK.
2
Department of Clinical Biochemistry, Aintree University Hospitals NHS
Trust, Liverpool, UK.
Correspondence to: Mrs Ann Woodward
Department of Diabetes and Endocrinology, University of Liverpool, Clinical
Sciences Centre, Aintree University Hospitals, Longmoor Lane, Liverpool,
L9 7AL, UK.
Tel: +44 (0) 151 529 5885
Fax: +44 (0) 151 529 5888
e-mail:
S Afr J Diabetes Vasc Dis
2010;
7
: 23–28
Abbreviations and acronyms
ACE inhibitor angiotensin converting enzyme inhibitor
ARB
angiotensin receptor blocker
BP
blood pressure
DBP
diastolic blood pressure
eGFR
estimated glomerular filtration rate
HDL
high-density lipoprotein
SBP
systolic blood pressure
