Heather Daly, Nurse Consultant - Diabetes.
University Hospitals of Leicester NHS TrustDiabetes could cost you your kidneys: act now! was the slogan for this year's World Diabetes Day. Nurses around the world have been taking part in a campaign to raise awareness about the importance of microalbuminuria screening.
Diabetes could cost you your kidneys: act now! was the slogan for this year's World Diabetes Day. Nurses around the world have been taking part in a campaign to raise awareness about the importance of microalbuminuria screening.
In the UK, about 100 nurses in 40 GP practices have been involved in the DEMAND (Developing Education on Microalbuminuria for Awareness of Renal and Cardiovascular Risk in Diabetes) campaign, carried out by the International Diabetes Federation (IDF) and the International Society of Nephrology (ISN). They are testing urine albumin in around 2,000 patients with Type 2 diabetes, and the results will be included in an analysis of checks on 40,000 patients worldwide.
In addition, the aim of the programme is to raise awareness among health professionals and patients about the importance of regular tests.
Diabetic nephropathy is one of the most common complications of diabetes. It affects up to 40% of patients with Type 2 diabetes, and 10-20% of these progress to end-stage renal disease (Cooper, 1998). With the rising prevalence of diabetes, especially Type 2, the number of people likely to develop renal problems is also expected to rise and, as three-quarters of renal function can be lost before symptoms appear, early detection and treatment are essential.
Microalbuminuria (an albumin excretion rate of 20-200mg per minute) is the earliest indicator of renal disease caused by diabetes. The National Institute for Clinical Excellence guidelines on Type 2 diabetes management recommend a microalbuminuria test at diagnosis and at least annually thereafter (NICE, 2002). Standard 10 of the National Service Framework for Diabetes also stresses the need for regular testing for renal and other complications (Department of Health, 2001). Unfortunately, in a busy diabetes clinic microalbuminuria is often the test that gets overlooked. In the DEMAND programme, albumin dipsticks and testing kits have been provided free of charge by Bristol-Myers Squibb and Sanofi-Synthelabo.
Each practice taking part in the DEMAND study tests and records urine albumin levels in 30 or more patients with Type 2 diabetes. Having seen how quick and easy it is to undertake a dipstick test in the clinic, it is hoped that more practices will include microalbuminuria testing routinely. As nurses run many diabetes clinics in primary care, it is likely that they will be the drivers for this important change.
According to the UK Renal Registry, 10% of Caucasian patients in the UK and 20% of those from south Asian and other ethnic groups who require renal replacement therapy have diabetes (UK Renal Registry, 2003). Diabetic kidney disease is now the leading cause of end-stage renal disease in the industrialised world.
If microalbuminuria is diagnosed and treated early, then end-stage renal disease can be delayed or prevented. In Type 2 diabetes, the UK Prospective Diabetes Study showed that tight blood glucose control (HbA1c <7%) reduced="" microvascular="" complications,="" including="" diabetic="" nephropathy="" (ukpds,="">7%)>
As coordinators of the DEMAND campaign, the IDF and ISN hope that, by raising awareness about the importance of diagnosing and treating microalbuminuria, patients with diabetes will soon ask for a test in much the same way as they already expect a blood pressure or cholesterol check. Coupled with the requirements of the National Service Framework for Diabetes, and in line with NICE guidance, DEMAND looks set to give microalbuminuria the high profile it needs if we are to reduce the growing burden of diabetic nephropathy on the NHS.
Cooper, M.E. (1998) Pathogenesis, prevention and treatment of diabetic nephropathy. Lancet 352: 213-219.
Department of Health. (2001)National Service Framework for Diabetes. London: The Stationery Office.
NICE (2002)Management of Type 2 Diabetes. Renal disease: prevention and early management. London: NICE.
UKPDS (1998)Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes (UKPDS 33). Lancet 352: 837-853.
UK Renal Registry.Report 2003. Available at: www.renalreg.com.