Blood pressure and diabetes..organising safe care
This graph is taken from an audit of the diabetes renal service at Heart of England NHS FT carried out by Dr Hugh Rayner (hugh.rayner@ heartofengland.nhs.uk). Patients were reviewed if their GFR dropped below 50ml/min/1.73m2 (age <65 years) or 40 (all patients). With the extra attention from the renal clinic physicians lowering the blood pressure, the drop in GFR was halted or slowed down significantly.
Of course some people did progress to renal failure, but the rate of deterioration was greatly slowed.
The renal clinic physicians concentrated on blood pressure, lowering it as much as possible. This was achieved using steps such as those described on this page.
Good control of blood pressure is important. But in patients who have only just become diabetic, particularly type 1 patients, if the blood pressure is normal, treatment is not needed. Control of blood pressure is very helpful reducing retinopathy etc when the retinopathy has actually developed. It is the HbA1c that is important at the onset. Diabetic nephropathy can be reversed if the HbA1c and blood pressure are extremely well controlled.
A register was kept of diabetic patients who had attended a hospital clinic. Their blood results were sent to a database and those with a GFR dropping below 50 (aged <65 years) or 40 (all patients) were identified by a computer enquiry each week.
- the renal physician spent one hour a week examining the database results
- the patients were under the care of their general practitioner/primary care team or hospital
- the renal physician reviewed the clinical events from the hospital electronic notes
- if the GFR graph showed an unexpected drop or a deteriorating trend, he would take action
- the action taken: writing to the primary care team pointing out there had been a GFR drop, and asking the primary care team if they wanted the patient to be examined and treated by the renal team.
- the primary care team were then be able to take action:
- either to review the patients to the renal team
- or to review anti-hypertensive medication
- very often the primary care team took up the offer of help
- When under the care of the renal team blood pressures were lowered as below.
- Patients were examined etc to identify that the kidney disease was due to diabetes, and not due to other treatable causes such as chronic urinary retention.
- Whilst some patients GFR deteriorated, there was usually enough time to slow down the rate of deterioration to allow fistula formation for dialysis.
- Using this method the number of patients with diabetes requiring dialysis has not increased, despite increases in the number of patients with diabetes.
- Patients with heavy proteinuria were also seen in the clinic as they
are at the highest risk of progressive nephropathy. Referral level for PCR
(protein:creatinine ratio) >100mg/mmol and for ACR (albumin:creatinine
ratio) is >70mg/mmol.
First, the cause of the kidney disease was identified, and non-diabetic causes were treated. Most were diabetes related and the renal physician targeted blood pressure. In the meantime the patient's diabetic physician was notified so he could control the diabetes as well as possible.
Concerning blood pressure, the drugs used were similar to those described (link given).
- ACE/ARB + calcium channel blocker + bendroflumethiazide/furosemide + 1/2 others.
- Patients were asked to buy home BP monitoring machine (e.g. Lloyds Chemist, about £15).
- They were asked to keep their blood pressure <140, the lower the better.
- When a patient attended the renal clinic, a letter summarising the consultation was written to the patient and a copy of this to the GP.
- These actions were taken to inform and support patients in managing their own blood pressure, so they understand its importance and could interact with their doctors and diabetes nurses more effectively.
- These protocols are similar to a similar study similar study published see
- Patients were discharged from the renal clinic once stable either to their GP or the diabetes clinic, or if their GFR was progressing towards dialysis, to the renal failure clinic.
- Lower BPs can be achieved if nurses can review and prescribe Diabetes Care 2011
- patients often become anaemic
- the target full blood count haemoglobin was 10.5-11.5. Increasing the haemoglobin further increases risks of other cardiovascular problems
- care was taken to avoid acidosis by measuring bicarbonate (acidosis increases progression)
See. The risk of recurrent stroke risks are related to systolic blood pressure SBP:
- 120-140 systolic..the lowest risk
- "Among patients with recent non–cardioembolic ischemic stroke, SBP levels during follow-up in the very low–normal (<120 mm Hg), high (140-<150 mm Hg), or very high (≥150 mm Hg) range were associated with increased risk of recurrent stroke."
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