SA JOURNAL OF DIABETES & VASCULAR DISEASE
ACHIEVING BEST PRACTICE
VOLUME 7 NUMBER 1 • MARCH 2010
27
serum creatinine, and decreases in eGFR occurred in both
microalbuminuric and nephropathic groups (Tables 2 and 3).
This may represent continued progression of renal damage
or may have been related to increased ACE inhibitor or ARB
usage. Tightening of BP control in type 2 diabetes with renal
disease has been associated with a decline in glomerular
filtration rate but this may reflect the effect of the drugs
rather than deterioration in the underlying disease.
3
Although efforts to improve glycaemic control were not
included in the protocol there was a significant improvement
in glycated haemoglobin in the microalbuminuria group.
The use of ACE inhibitors may have contributed to an
improvement in insulin sensitivity in the microalbuminuric
group. However, we believe this to be much more likely
due to the regular structured nurse contact, creating a non-
specific support element known as the ‘Hawthorne effect’
which has a tendency to improve motivational change.
16
Improved glycaemic control in the absence of specific
intervention strategies has been previously reported in a
nurse-led cardiovascular risk reduction clinic, which provided
frequent patient contact.
17
Close liaison was required between the nurse and
supervising physicians, as medical advice was needed for
15–20% of all appointments (almost always a discussion
with case notes after the clinic). As with other studies using
intensive ACE inhibitor or ARB treatment, hyperkalaemia was
sometimes a problem,
3
and 19 of our patients required ACE
inhibitor or ARB dose reductions. We found a higher default
rate than in our similar clinics for patients with type 2 diabetes
without renal disease.
12
A number of these defaults were
related to deaths, repeated hospital admissions or recurrent
illness; emphasising that type 2 patients with diabetic renal
disease often have significant pathology.
In conclusion, our flexible nurse-led patient-centred system
of care, using a validated flexible clinical algorithm, has been
shown to effectively reduce BP levels and protein excretion in
type 2 patients with diabetic renal disease. Disappointingly,
however, renal function (as measured by serum creatinine
and eGFR) continued to deteriorate. Additionally, a number
of patients could not attend all appointments (largely related
to co-morbidity). Nevertheless, we believe our system of care
still has much to offer these extremely high-risk patients.
Conflicts of interest
This study was funded by an unrestricted educational grant
from Sanofi-Synthelabo.
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Key messages
Patients with diabetic renal disease require optimal BP
•
control
Optimal BP control can be achieved by intensified man-
•
agement of hypertension, including use of ACE and ARB
therapy
A nurse-led clinic can provide an effective structured ap-
•
proach to intensified management
Patients with type 2 diabetes and renal disease can be
•
complex
Intensified nurse-led management of hypertension
•
required physician’s advice/intervention in 15–20% of
nurse consultations
