ACHIEVING BEST PRACTICE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
26
VOLUME 7 NUMBER 1 • MARCH 2010
(without any treatment changes). Thus, of the 104 originally
referred, systolic BP fell from 153
±
21 to 143
±
21 mmHg (
p
<
0.0001) and diastolic BP from 75
±
14 to 72
±
10 mmHg (
p
=
0.008). For the 71 who completed the programme, systolic
BP fell from 152
±
21 to 131
±
18 (
p
<
0.0001) and diastolic
BP from 76
±
13 to 68
±
10 (
p
<
0.0001). ACE inhibitor
and ARB usage increased from 66% to 91% at review (
p
=
0.0004), and use of three or more antihypertensive drugs
from 28% to 49% (
p
=
0.015). Those with microalbuminuria
required on average six visits to achieve target BP, whereas
eight visits were needed for those with nephropathy. With
the 12-month review appointment, the total period of
treatment was approximately 18–20 months. Physician
advice was required in 15% of microalbuminuria and 20%
of nephropathy patients. Hyperkalaemia (serum potassium
>
5.0 mmol/l) occurred in 47% of nephropathy patients and
19% of those with microalbuminuria (
p
=
0.03).
Microalbuminuric group
Table 2 shows the progress of this group (
n
=
52) from clinic
entry to the later review. SBP and DBP fell, (
p
<
0.0001) during
the period of intervention, which was largely sustained at
review (Fig. 2). The proportion of patients treated to target
rose from 25 to 58% (
p
=
0.001). More patients were on
either ACE inhibitor or ARB therapy, 65–92% (
p
=
0.001),
with 39 (75%) taking the maximum dose and seven (13%)
prescribed the lowest tolerated dose. Four (8%) had to stop
ACE inhibitor or ARB treatment because of hypotension or
persistent hyperkalaemia. There was a rise in creatinine, (
p
<
0.001) and a decline in eGFR, (
p
<
0.0001) in the group as
a whole. The overall use of antihypertensive, lipid-lowering
and aspirin therapy, increased significantly.
Nephropathy group
Details of this group are shown in Table 3. From entry to
the clinic systolic BP fell, (
p
<
0.0001) as did diastolic BP (
p
=
0.004), which was also largely sustained at review (Fig. 2).
The proportion of patients treated to target rose from 21 to
63% (
p
=
0.008). The numbers of patients on ACE inhibitor
or ARB therapy increased to 89% (although there was a high
usage at baseline), with 12 (63%) taking maximum dose and
one (5%) prescribed the lowest tolerated dose. Two (10%)
had to stop ACE inhibitor or ARB because of hypotension
and persistent hyperkalaemia. There was an increase in serum
creatinine in this group, (
p
=
0.0008) and a decline in eGFR
(
p
=
0.002). Lipids did not change (however, statin use in this
group was high at baseline), and there were non-significant
increases in antihypertensive and antiplatelet therapy.
Discussion
This study describes a novel attempt to improve BP and other
risk factor management in patients with type 2 diabetes and
diabetic renal disease. The benefits of intensive intervention
in patients with type 2 diabetes and microalbuminuria have
been convincingly reported by Gaede and colleagues.
13
In our study, intensified management of hypertension
was highly successful; the important achievement was the
sustained improvement at review one year later, with over
60% of patients in both groups maintaining target BP under
130/80 mmHg.
Collaborative working to improve hypertension in diabetic
renal disease has been recently highlighted by the American
Diabetes Association, using nurses and pharmacists to
apply multiple risk factor modification strategies.
14
Our
findings support a recently reported pharmacist intervention,
focusing on target-driven structured care for diabetic renal
disease achieving similar BP targets and optimisation of ACE
inhibitor/ARB therapy.
15
Compared with this previous study,
the patients in our study required more visits to achieve
optimal BP control, showed a decrease in eGFR and also
required 15–20% physician intervention (this may have been
due to greater morbidity with
>
30% cardiovascular disease);
patients could therefore have been further along the disease
trajectory.
Intensified intervention resulted in 90% of patients
receiving ACE inhibitor or ARB therapy, the majority taking
a maximum dose. As most of the microalbuminuric patients
were taking either ACE inhibitor or ARB therapy the dramatic
reduction in microalbuminuria may have been a direct benefit
of these drugs. Another factor influencing the high rate ACE
inhibitor or ARB usage may have been the vigilant monitoring
for side effects.
Disappointingly we found that renal function deteriorated
during treatment and follow-up. Significant increases in
Table 3.
Comparison of nephropathy group data at entry and review (
n
=
19)
Characteristic
Entry
Review
p
-value
Blood pressure
≤
130/80 mmHg
4 (21%)
13 (63%)
p
=
0.008*
Creatinine (mmol/l)
116
±
39
143
±
43
(
n
=
18)
p
=
0.0008
ARB/ACE inhibitor
13 (68%)
17 (89%)
p
=
0.2*
Three or more antihypertensive drugs
6 (32%)
8 (42%)
p
=
0.7*
eGFR (ml/min)
66
±
25
51
±
19
p
=
0.002
Glycated haemoglobin (%)
8.5
±
1.6
8.0
±
1.7
(
n
=
17)
p
=
0.6
Total cholesterol (mmol/l)
4.8
±
1.4
(
n
=
17)
4.5
±
1.3
p
=
0.7
HDL cholesterol (mmol/l)
1.1
±
0.3
(
n
=
17)
1.1
±
0.3
p
>
0.999
Statin
16 (84%)
17 (89%)
p
>
0.999*
Antiplatelet
15 (79%)
19 (100%)
p
=
0.1
Three (16%) patients reverted to microalbuminuria at review
P
-values by Chi-squared test and Fisher’s exact test for categorical variables and
paired
t
-test for continuous variables unless stated
Data given as
n
(%) for categorical variables and mean
≥
SD for continuous
variables
ACE inhibitor
=
angiotensin converting enzyme inhibitor; ARB
=
angiotensin
receptor blocker; eGFR
=
estimated glomerular filtration rate;
HDL
=
high density lipoprotein
