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Diabetes care and chronic kidney disease

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Diabetes specialist nurse Gillian Atherton on Bradford Royal Infirmary’s hugely successful service improvement project on diabetes care for patients with chronic kidney disease.

In 2007, the diabetes unit seconded a diabetes specialist nurse two days a week, to give integrated specialist diabetes care for pre-dialysis patients, patients on haemodialysis or peritoneal dialysis, renal transplant patients or patients on a renal palliative care pathway.

The renal unit serves both Bradford City and Airedale Primary Care Trusts.

The approximate number of renal patients with diabetes varies weekly but there are approximately:

  • 70 patients on haemodialysis;

  • 15 patients on peritoneal dialysis;

  • 32 renal transplant patients;

  • 20 pre-dialysis.

These patients with renal disease often have complex needs and other medical conditions. They usually have to attend other hospital departments and can have many appointments which result in excessive time being spent in a hospital environment, often with each speciality working in isolation.

This new role was developed to improve communication, primarily between the diabetes and renal team but also the vascular and specialist foot ulcer clinic.

Patients could be seen when they attended renal appointments or whilst on dialysis, reducing the number of hospital appointments and improving communication between the specialties.

Patients with renal disease often have a lower standard of diabetes care as they miss ppointments due to conflicting appointment times or may feel too unwell to attend.

This dual post was informally started approximately five years ago but as the workload and benefits increased, a joint decision by the renal and diabetes units was reached to develop a new diabetes/renal specialist nurse post.

Hypoglycaemia was problematic for patients having haemodialysis. Many patients had frequent episodes of hypoglycaemia during dialysis as they often can’t eat (as this causes hypotension) and glucose is dialysed out but not insulin.

A research project was undertaken by one of the haemodialysis nurses (Rachel Lawton) resulting in a change to glucose dialysate which has reduced the number of hypoglycaemic episodes and severity of these episodes.

The renal diabetes team incorporates a diabetes specialist nurse, the haemodialysis team (one key worker), the peritoneal dialysis team, renal transplant team and two pre-dialysis nurses, renal dietitians as well as the renal ward. There is also a podiatrist who has dedicated time to review patients on haemodialysis and the audit undertaken showed a reduction in foot ulcer rates as well as earlier detection of neuropathic and vascular complications.

When this new role started, another diabetes specialist nurse was employed to take over some of the general diabetes workload and clinic rooms were allocated on the haemodialysis unit.

Increased, dedicated diabetes renal in-put would allow expansion of the service to incorporate joint pre-dialysis sessions and support the renal satellite service as well provide more education sessions for both staff and patients.

There is also a need to improve retinal screening services for these patients.

There have been several benefits from introducing this service: improved podiatry service has reduced foot ulceration rates; the podiatrist has also taught basic foot examination to key workers on the haemodialysis unit which improves complication detection rates.

Hba1c results have improved and diabetes treatments are optimised.

Introducing glucose dialysate has reduced the hypoglycaemia episodes.

Establishing closer links with the renal team has meant problems are discovered and treated quicker.

We have held a ‘renal/diabetes study day’ for healthcare professionals, to help improve the knowledge and de-mystify some of the problems for other health-care professionals. This evaluated very well.

Hba1c levels are taken three-monthly- results are reviewed at monthly blood result meetings for haemodialysis patients, patients with any problematic results are reviewed quickly.

Patients with diabetes often have deterioration in glycaemic control, after starting peritoneal dialysis due to the increased glucose load.

Working in conjunction with the peritoneal dialysis team, intra-peritoneal insulin regimens have been introduced; audit of IP insulin has showed improvement in glycaemic control and reduced the incidence of hypoglycaemia and no increase in peritonitis rates.

Joint work with the peritoneal dialysis team has meant that diabetes treatment is assessed and changed quickly if control deteriorates with PD.

Screening for post transplant diabetes now occurs and patients are fast-tracked to the diabetes team as soon as abnormal blood glucose levels are found. Patients have glucose tolerance tests to confirm diabetes and referred to the appropriate team for follow up care. Patients are referred pre-transplant as well to optimise control ready for transplantation and followed up intensively afterwards, several patients have started on insulin pump therapy.

Patients have commented that joint appointments (when available) improve their hospital experience, collaboration between all renal and diabetes departments has improved communication and overall improved detection of complications and reduction life-disrupting events.

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