The extent of albuminuria in individuals with diabetes within Heart of Birmingham PCT Mark Jesky Research Registrar.

The extent of albuminuria in individuals with diabetes within Heart of Birmingham PCT

Mark JeskyResearch Registrar

Background• Most management of diabetes (and microalbuminuria) takes

place in primary care

• Factors associated with development and progression of nephropathy well established– Good glycaemic control– Blood pressure management– ACEi/ ARB as antihypertensive agents of choice

• CKD frequently under-recognised

• Nephrology input later in course of disease

Background

• HoB PCT– Young, ethnically diverse population– has the highest take up rate of renal replacement

therapy within UK

– Enhanced, electronic recording of individuals• ≥40 years or identified as having a vascular disease

• Gain insight into practice within primary care setting

NICE CKD Guidelines: Diabetes

Audit Questions

• What is the extent of albuminuria within primary care diabetic population?

• Are NICE CKD guidelines being followed?– checking eGFR and ACR at least annually– if ACR elevated, are ACEi/ARBs being prescribed?

• Are any factors (age, gender, ethnicity) associated with not having ACR performed?

Diabetes and Measurement of Renal function

• June 2011 extract• 21,529 classified as diabetic– HoB population ≈ 300,000– 7.2%

• Of those 21,529, within last 12 months– 69.0% (14,854) had an eGFR recorded– 69.0% (14,857) had an ACR recorded

• 62.5% in National diabetes audit 2010• ~50% National diabetes audit 2008

– 51.2% (11,033) have both eGFR and ACR

Degree of Albuminurian= Normo-

albuminuraMicro-albuminuria

Macro-albuminuria

Male 7632 5204(68.2%)

1982(26.0%)

446(5.8%)

Female 7225 5493(76.0%)

1375(19.0%)

367(5.1%)

Combined 14857 10697(72.0%)

3357(22.6%)

803(5.4%)

National Diabetes Audit 73.5% 19.1% 7.4%

4140 (28%) diabetic individuals in HoB PCT have some degree of albuminuria

Adherence to NICE guidelines(Both ACR and eGFR reported)

eGFR ≥ 60 eGFR 30 -59 eGFR <30

No AlbuminuriaACR ≤ 2.5 (M), ACR ≤ 3.5 (F)

6335(57.4%)

1439(13.3%)

63(0.57%)

AlbuminuriaACR > 2.5 (M),ACR > 3.5 (F)

1963(17.8%)

1017(9.2%)

216(2.0%)

Adherence to NICE guidelines(Both ACR and eGFR reported)

eGFR ≥ 60 eGFR 30 -59 eGFR <30

No AlbuminuriaACR ≤ 2.5 (M), ACR ≤ 3.5 (F)

6335(57.4%)

1439(13.3%)

63(0.57%)

AlbuminuriaACR > 2.5 (M),ACR > 3.5 (F)

1963(17.8%)

1017(9.2%)

216(2.0%)

42.6% have either albuminuria or moderate CKDc.f. 45% in National Diabetes Audit

Adherence to NICE guidelinesACEi/ ARB usage

eGFR ≥ 60 eGFR 30 -59 eGFR <30

No AlbuminuriaACR ≤ 2.5 (M), ACR ≤ 3.5 (F)

6335(57.4%)

1439(13.3%)

63(0.57%)

AlbuminuriaACR > 2.5 (M),ACR > 3.5 (F)

1963(17.8%)

1017(9.2%)

216(2.0%)

Of these 2980,

68.2% (2032) on ACEi/ARB,31.8% (948) not

Checking ACR

• Demonstrated ACR not consistently checked• Can any factors associated with this be

identified?

Checking ACRACR measured ACR not measured

Gender (% female) 48.6 (100) 50.6 (100)

Age (years) 61.0 (100) 58.6 (100)

Systolic BP (mmHg) 132.6 (97.9) 132.4 (93.3)

Diastolic BP (mmHg) 76.0 (99.8) 76.6 (96.1)

HbA1c (%) 7.6 (96.9) 7.7 (93.0)

eGFR (% <60ml/min) 32.7 (76.3) 21.1 (69.0)

Bangladeshi (%) 72.3 27.7Black (%) 72.8 27.2Indian (%) 72.4 27.6Pakistani (%) 64.4 35.6White (%) 68.9 31.1Not Stated (%) 67.5 32.5

Checking ACRACR measured ACR not measured

Gender (% female) 48.6 (100) 50.6 (100)

Age (years) 61.0 (100) 58.6 (100)

Systolic BP (mmHg) 132.6 (97.9) 132.4 (93.3)

Diastolic BP (mmHg) 76.0 (99.8) 76.6 (96.1)

HbA1c (%) 7.6 (96.9) 7.7 (93.0)

eGFR (% <60ml/min) 32.7 (76.3) 21.1 (69.0)

Bangladeshi (%) 72.3 27.7Black (%) 72.8 27.2Indian (%) 72.4 27.6Pakistani (%) 64.4 35.6White (%) 68.9 31.1Not Stated (%) 67.5 32.5

Audit Questions

• What is the extent of albuminuria within primary care diabetic population?

• Are NICE CKD guidelines being followed?– checking eGFR and ACR at least annually– if ACR elevated, are ACEi/ARBs being prescribed?

• Do any factors (age, gender, ethnicity) predispose to not having tests done?

Summary• ACR assessed in under 70% diabetic population• Just over half had ACR and eGFR recorded in last 12 months

• ACEi/ ARB usage not as extensive as should be

• People with ACR not checked tend to be – Younger– Pakistani, White, ethnicity not stated– Less likely to have eGFR <60– Less likely to have other parameters checked

• Implications for risk stratification• More can be done to try to reduce rate of progression in this high risk

population

Acknowledgements

• Amanda Lambert• Dr Felix Burden• Dr Paul Cockwell