Screening for microalbuminuria in patients with type 2 diabetes is incomplete in general practice

Transcription

1 Da Med J / September DANISH MEDICAL JOURNAL Screeig for microalbumiuria i patiets with type 2 diabetes is icomplete i geeral practice Søre Tag Kudse 1, Thomas Hammershaimb Mosbech 2, Birtha Hase 1, Else Køig 3, Peter Christia Johse 2 & Ae-Lise Kamper 4 ABSTRACT INTRODUCTION: Natioal Daish guidelies recommed screeig for microalbumiuria with assessmet of uriary albumi/creatiie ratio at least aually i patiets with type 2 diabetes. To which extet such screeig is actually performed is ot kow. MATERIAL AND METHODS: A total of 2,057 patiets with type 2 diabetes were radomly selected from 64 geeral practitioers (GPs) from differet geographical areas of Demark. Cliical ad laboratory data o the idividual patiets were collected through the GPs electroic medical patiet records; particular emphasis was give to aual screeig for microalbumiuria. RESULTS: The mea age of the patiets was 66.2 ± 11.6 years ad 58.7% were male. Oly 57.2% of the patiets had bee screeed for microalbumiuria with ay method withi the precedig 12 moths period; of these 76.0% had ormo- ad 21.0% had microalbumiuria, whereas 3.0% had overt proteiuria. I cotrast, 97.6% of patiets had had a miimum of oe plasma-creatiie measuremet withi the past year. CONCLUSION: I Daish primary care, screeig for microalbumiuria i type 2 diabetes is isufficietly implemeted, whereas real fuctio is evaluated i almost all patiets by plasma-creatiie measuremets. The importace of diagosig microalbumiuria i patiets with type 2 diabetes eeds to be emphasised. FUNDING: The project has received fudig i the form of a research grat from Boehriger Igelheim, Demark. TRIAL REGISTRATION: ot relevat. The prevalece of chroic kidey disease (CKD) is high i type 2 diabetes [1, 2]. The risk of cardiovascular disease (CVD) is markedly icreased whe both diabetes ad CKD are preset [3]. I ed-stage kidey disease, 50% of patiets die withi 4-5 years after iitiatio of dialysis [4]. Icipiet diabetic ephropathy ca be detected by the appearace of microalbumiuria [5]. I patiets with type 2 diabetes ad microalbumiuria, the developmet of diabetic ephropathy ca be preveted or delayed by blood pressure cotrol ad medical blockade of the rei-agiotesi system [6]. Moreover, itesified combied multi-pharmacological ad lifestyle itervetios toward traditioal CVD risk factors may reduce real failure ad cardiovascular evets by 50% i patiets with type 2 diabetes with microalbumiuria [7]. A cost-effectiveess aalysis showed that itesive therapy was more cost-effective tha covetioal treatmet from a healthcare payer perspective [8]. It is therefore of major importace to idetify patiets with type 2 diabetes with microalbumiuria i order to offer optimal protective therapy agaist real failure ad cardiovascular evets. The Daish atioal guidelies recommed screeig for microalbumiuria by assessmet of the uriary albumi/creatiie ratio (UACR) at least aually i patiets with type 2 diabetes [9]. I hospital settigs, data o the implemetatio of this screeig ca be obtaied from The Natioal Idicator Project (NIP) [10]. However, there are oly limited data o screeig for microalbumiuria or CKD i the majority of Daish patiets with type 2 diabetes who are followed i primary care settigs [11]. The primary purpose of the preset study was thus to evaluate the frequecy of screeig for microalbumiuria, albumiuria ad real fuctio i patiets with type 2 diabetes followed i primary care settigs i Demark. MATERIAL AND METHODS We aimed at icludig a miimum of 2,000 patiets with type 2 diabetes i the study (correspodig to almost oe percet of the total populatio of patiets diagosed with type 2 diabetes i Demark). The iclusio criteria were: 1) Diagosis of type 2 diabetes 2) Duratio of diabetes 2 years. The exclusio criteria were: 1) Diabetes maaged i secodary care uit 2) Dialysis or history of kidey trasplatatio 3) Other medical kidey disease (e.g. polycystic kidey disease, glomeruloephritis). Geeral practitioer selectio: Sixty-four geeral practitioers (GPs) participated i the study. They were ra- ORIGINAL ARTICLE 1) Departmet of Iteral Medicie ad Edocriology (MEA), Aarhus Uiversity Hospital 2) DTU Data Aalysis, Techical Uiversity of Demark 3) Geeral practice, Lygby 4) Departmet of Nephrology, Rigshospitalet Da Med J 2012;59(9):A4502

2 DANISH MEDICAL JOURNAL Da Med J / September TABLE 1 Cliical ad laboratory characteristics of study participats. Screeed Uscreeed Total p-value a Patiets, 1, ,057 Male/female, % 60.1/ / / Age b, mea ± SD, years 66.1 ± ± ± Duratio of diabetesc, media (IQR), years 5.0 ( ) 5.0 ( ) 5.0 ( ) , ,760 Active smokers, % Atihyperglycaemic treatmet, % treated Atihyperglycaemic drugs received c, media (IQR), 1.0 ( ) 1.0 ( ) 1.0 ( ) 0.42 Metformi, % treated < 0.01 Isuli, % treated Hypertesio, % diagosed < 0.01 Atihypertesive treatmet, % treated < 0.01 Atihypertesive drugs received c, media (IQR), 2.0 ( ) 1.0 ( ) 1.0 ( ) < 0.01 Kow cardiovascular disease, % Stati, % treated < 0.01 Acetyl salicylic acid, % treated < 0.01 Body mass idex b, mea ± SD, kg/m 2 Blood pressure b, mea ± SD, mmhg Systolic Diastolic 30.5 ± ± , ± 8.4 1, ± ± ± ± ± , ± 9.0 1,899 UAE, % ormo-/microalbumiuria/proteiuria 76.0/21.0/3.0 P-creatiie, % ormal/elevated/severely elevated 76.0/21.5/ /22.7/ /22.0/ , ,008 Total cholesterol c, media (IQR), mmol/l LDL cholesterol c, media (IQR), mmol/l HbA 1cc, media (IQR), % GPs, % 4.2 ( ) 1,163 1, ( ) ( ) 1,996 1,959 1,722 I solo practices I big cities GP = geeral practitioer; HbA 1c = glycated haemoglobi; IQR = iterquartile rage; LDL = low-desity lipoprotei; P = plasma; SD = stadard deviatio; UAE = uriary albumi excretio. a) p-values refer to Studet s t test, 2 -test, Wilcoxo s test, or Fisher s exact test, as appropriate, see Statistical aalyses. b) Normally distributed variable. c) No-ormally distributed variable < 0.01 < domly selected from differet geographical regios of Demark ad couted GPs from both solo practices ad group settigs. Patiet selectio: All patiets with type 2 diabetes were idetified by the GP i collaboratio with a specially traied urse through a search i the idividual GP s electroic medical patiet records for: 1. Registered diagosis of diabetes (Iteratioal Classificatio of Primary Health Care (IPCP), Iteratioal Classificatio of Diseases 10th ed. (ICD10)) 2. Preset or previous prescriptio of specific atidiabetic medicatio (e.g. metformi, isuli) 3. Free text search for the word diabetes. From this list, a media of 35 (iterquartile rage 30-35) patiets were radomly chose. Fially, the selected patiets were assiged a log umber after which oly the GP had access to the data regardig the patiets idetity. The primary ed-poits were the proportio of patiets screeed for microalbumiuria withi the precedig 12 moths ad the level of uriary albumi excretio amog these patiets. The patiets stadard cliical ad laboratory characteristics were recorded, icludig age, sex, duratio of diabetes, history of CVD ad hypertesio, smokig, weight, body mass idex, blood pressure, pharmacological treatmet (glucose-lowerig drugs, atihypertesive treatmet, aticoagulat medicatio, lipid-lowerig medicatio), ad the followig

3 Da Med J / September DANISH MEDICAL JOURNAL biochemical variables: glycated haemoglobi (HbA 1c ), plasma-creatiie, total ad low-desity lipoprotei cholesterol. Statistical aalyses Statistical aalyses were performed i collaboratio with staff at Techical Uiversity of Demark (DTU), where the database is hosted. Patiets with a miimum of oe aalysis of uriary albumi excretio (UAE) (ay method) withi the precedig 12 moth period were classified as screeed, whereas the rest of the patiets were classified as uscreeed for microalbumiuria or proteiuria. Data are preseted as mea ± stadard deviatio (SD, ormally distributed parameters) or as media (iterquartile rage (IQR)). Comparisos betwee groups were performed with Studet s t-test (cotiuous variables) or 2 -test with Pearso s correctio (discrete variables). For o-ormally distributed parameters, Wilcoxo s test or Fisher s exact test were applied. The study was approved by The Daish Data Protectio Agecy, ad the participatio of the GPs was approved by the Daish Medical Associatio. Trial registratio: ot relevat. RESULTS A total of 2,057 patiets with type 2 diabetes were icluded i the study. Their cliical ad laboratory characteristics are give i Table 1. Their mea age was 66.2 ± 11.6 years, 58.7% were male, ad the media diabetes duratio was 6.6 (IQR: ) years. Screeig for microalbumiuria: 57.2% of the patiets had bee screeed with a measuremet of UAE (ay method) withi the precedig 12 moth period; of these 76.0% had a ormal albumi excretio ad 21.0% had microalbumiuria, whereas 3.0% had overt proteiuria (Figure 1). The method for determiig a l bumi excretio i urie varied: I 41.9%, a miimum of oe UACR had bee performed, i 2.1% a 24-hour urie sample had bee collected, whereas uriary albumi cocetratio or protei cocetratio had bee measured i a spot urie sample i 17.1% ad 5.8%, respectively (Figure 2). I a mior proportio of patiets, more tha oe method had bee used; for this reaso, the total figure slightly exceeds the total of 57.2%. Screeed ad uscreeed patiets did ot differ with regard to age, sex, duratio of diabetes, smokig, atihyperglycaemic treatmet, frequecy of kow CVD, plasma-creatiie, or HbA 1c. I cotrast, a slightly higher proportio amog screeed tha amog uscreeed patiets was diagosed with hypertesio (73.4 versus 66.1%, respectively, p < 0.01); likewise, screeed patiets were more likely to be treated with acetylsalicylic acid (ASA) ad with a stati tha uscreeed patiets % % FIGURE 1 = 881 = 894 Uscreeed FIGURE 2 = 881 No measuremet = 352 Uriary albumi (spot urie) = 247 = 35 Normoalbumiuria Microalbumiuria Proteiuria = 44 Uriary albumi (24-hour) = 120 Uriary protei (spot urie) = 861 Uriary albumi/ crea ie ra o (p < 0.01 for both comparisos, Table 1). The frequecy of screeig for microalbumiuria did ot differ betwee GPs i solo versus GPs i group settigs or betwee GPs i cities (> 100,000 ihabitats) with uiversity hospitals versus GPs i smaller tows (p > 0.3 for both comparisos, Table 1). Real fuctio: 97.6% of the patiets had a miimum of oe measuremet of plasma-creatiie withi the past year. Of these, 75.7% had ormal plasma-creatiie < 90 micromol/l ad oly 2.3% had severely elevated plasma-creatiie levels 150 micromol/l. DISCUSSION The mai result of the preset study was that oly 57.2% of the patiets with type 2 diabetes i Daish primary care had udergoe the recommeded screeig for microalbumiuria durig the precedig 12 moth period. Amog the screeed patiets, 21% had micro- Type 2 diabetic patiets ( = 2,057) without screeig for microalbumiuria ( uscreeed ) or with ormoalbumiuria, microalbumiuria, or proteiuria. Screeig methods for uriary albumi excretio i type 2 diabetic patiets. I a mior proportio of patiets, more tha oe method had bee used; for this reaso, the total percetage of screeig methods slightly exceeds the total of 57.2% screeed patiets.

4 DANISH MEDICAL JOURNAL Da Med J / September The uriary albumi/ creatiie ratio is the recommeded aalysis for microalbumiuria. albumiuria ad 3% had overt proteiuria. Importatly, real fuctio had bee evaluated by measuremet of plasma-creatiie i 97.6% of patiets of whom the majority (75.7%) had ormal plasma-creatiie level. Oly 2.3% had markedly elevated plasma-creatiie levels ( 150 micromol/l) idicatig moderate to severe real failure. Diabetic ephropathy is a commo ad serious complicatio i patiets with type 2 diabetes. It may lead to ed-stage real failure with a subsequet eed for real replacemet therapy [4]. I additio, severe real failure is associated with a marked risk for CVD. CKD ad the associated CVD cause great sufferig for the idividual patiet ad these coditios impose a extesive burde o healthcare budgets. Fortuately, may risk factors for the developmet ad progressio of diabetic ephropathy [12] ad CVD [13] have bee idetified, ad there is ow solid evidece that early, targeted pharmacological itervetio i the icipiet microalbumiuric stage of the disease is highly protective agaist the developmet of overt ephropathy [14] ad the serious cardiovascular evets i this patiet group [7, 15]. Screeig for the developmet of microalbumiuria is therefore pivotal i order to idetify patiets with icipiet ephropathy eligible for this itervetio. Thus, assessmet of the uriary albumi excretio at least aually is recommeded i atioal guidelies o type 2 diabetes [9]. Screeig for microalbumiuria ad albumiuria ca be easily ad coveietly coducted with the assessmet of UACR i a sigle urie sample. If the UACR is i the microalbumiuric level of mg/g, aother two urie samples are eeded to establish the presece of microalbumiuria. Furthermore, uriary tract ifectio has to be ruled out. I case of a markedly icreased UACR, a 24-hour uriary samplig is recommeded i order to obtai a accurate measure of albumiuria. Determiatio of the albumi cocetratio i a spot urie sample is ot recommeded due to the ifluece of the uriary volume. I the preset study, 41.9% had a miimum of oe UACR aalysis, whereas a 24-hour uriary samplig had bee performed i 2.1%. The iappropriate method with measuremet of albumi or protei cocetratio i a spot urie sample had bee used i 17.1% ad 5.8%, respectively. Hece, there seems to be ucertaity as to the optimal method whe screeig for microalbumiuria ad albumiuria. The almost complete moitorig of real fuctio by blood tests demostrates a very high awareess of the risk for real disease i type 2 diabetes. Thus, the rather poor screeig rate for microalbumiuria probably reflects a poorer kowledge of the importace ad therapeutic cosequeces of this coditio. We foud o ifluece of the GP s solo versus group settig or urbaisatio o the screeig patter. Likewise, key cliical ad laboratory characteristics were comparable i screeed ad uscreeed patiets, which idicates a systematic problem i screeig setup as opposed to a deliberate choice of refraiig from screeig specific patiet categories (e.g. very old patiets, low-risk patiets, etc.). Møller et al retrospectively examied the records from 97 patiets referred from GPs to a secodary care diabetes cetre i the period [10]. The frequecy of screeig for microalbumiuria i these patiets was 53% durig the precedig two years. Takig ito accout that patiets i that study were selected by referral to a secodary diabetes cetre, which presumably had bee preceded by a period of itesified cotact to the GP, the screeig level was low. Thus, the screeig frequecy of 57% i a period of oly oe year i the preset much larger group of uselected type 2 diabetic patiets might idicate a slight icrease i uriary screeig frequecy durig recet years. This hypothesis is supported by aother study of 80 patiets which reported a eve lower microalbumiuria screeig rate of oly 34% durig the two-year period from [16]. Curretly, a ew Setiel Data Capture system is uder implemetatio i Daish primary care [11]. The system will provide idividual feedback quality reports for the GP o key data from patiets with chroic diseases, icludig data o screeig for complicatios i patiets with diabetes. Whe this system is fully implemeted, presumably withi a few years, this will allow for the extractio of data at the atioal level for research purposes such as the preset study, as is the case

5 Da Med J / September DANISH MEDICAL JOURNAL for NIP [10]. This ew feedback ad moitorig modality is likely to improve the screeig activity i Daish primary care. The stregths of the preset study obviously rest o the large umber of icluded patiets ad cliics, allowig for a statistically precise estimate of Daish GPs true microalbumiuria screeig frequecy i patiets with type 2 diabetes, as well as for statistical aalyses of potetial factors related to GPs (size of practice, geographical variatios) or patiets (age, sex, co-morbidity etc.) that could theoretically ifluece screeig habits. Moreover, the primary care based desig of the preset study with iclusio of differet types of GPs (solo/group) from all regios of Demark stregthes the exteral validity of the study ad miimises the risk of selectio bias compared with studies o patiets referred to secodary care settigs [10]. Oe potetial weakess of the study relates to its reliace o the data quality of the electroic medical patiet records of the participatig GPs. O the other had, this problem would truly reflect the real life situatio for the GP regardig the maagemet of patiets with type 2 diabetes, icludig screeig for microalbumiuria, ad it therefore does ot hamper the exteral validity of the study. I coclusio, screeig for microalbumiuria i type 2 diabetes i Daish primary care is isufficietly implemeted, whereas real fuctio is evaluated i a lmost all patiets by plasma-creatiie measuremets. More iformatio o optimal uriary screeig methods ad the importace of diagosig microalbumiuria ad albumiuria seems to be eeded. evidesbaseret vejledig. rettet.pdf (1 Ja 2012) 10. Moller FG, Lykke R, Kaersvag L et al. Quality idicators for type 2 diabetes at referral to diabetes cetre. Ugeskr Læger 2010;172: DAK-E Dask Almemedicisk Kvalitetsehed. Dask Almemedicisk Database. DAMD. Årsberetig damd_aarsberetig_ pdf. 12. Kudse ST, Laugese E, Hase KW et al. Ambulatory pulse pressure, decreased octural blood pressure reductio ad progressio of ephropathy i type 2 diabetic patiets. Diabetologia 2009;52: Laugese E, Rosse NB, Poulse PL et al. Pulse pressure ad systolic ightday ratio iteract i predictio of macrovascular disease i patiets with type 2 diabetes mellitus. J Hum Hypertes 2012;26: Mogese CE, Keae WF, Beett PH et al. Prevetio of diabetic real disease with special referece to microalbumiuria. Lacet 1995;346: Ibse H, Olse MH, Wachtell K et al. Reductio i albumiuria traslates to reductio i cardiovascular evets i hypertesive patiets with left vetricular hypertrophy ad diabetes. J Nephrol 2008;21: Falko E, Kragstrup J, Betze N, Schroll H. Quality developmet i geeral practice usig diagostic classificatio Expaded Daish ICPC i the computerized medical records. Ugeskr Læger 2002;164: CORRESPONDENCE: Søre Tag Kudse, Medicisk Edokriologisk Afdelig (MEA), Aarhus Uiversitetshospital, 8000 Aarhus C, Demark. stk@dadlet.dk ACCEPTED: 27 Jue 2012 CONFLICTS OF INTEREST: Disclosure forms provided by the authors are available with the full text of this article at LITERATURE 1. Koro CE, Lee BH, Bowli SJ. Atidiabetic medicatio use ad prevalece of chroic kidey disease amog patiets with type 2 diabetes mellitus i the Uited States. Cli Ther 2009;31: Middleto RJ, Foley RN, Hegarty J et al. The urecogized prevalece of chroic kidey disease i diabetes. Nephrol Dial Trasplat 2006;21: Foley RN, Murray AM, Li S et al. Chroic kidey disease ad the risk for cardiovascular disease, real replacemet, ad death i the Uited States Medicare populatio, 1998 to J Am Soc Nephrol 2005;16: Daish Society of Nephrology. Daish Nephrology Registry, Aual Report %C3%85rsrapport% pdf. 5. Mogese CE, Chachati A, Christese CK et al. Microalbumiuria: a early marker of real ivolvemet i diabetes. Uremia Ivest 1985;9: Parvig HH, Lehert H, Brocher-Mortese J et al. The effect of irbesarta o the developmet of diabetic ephropathy i patiets with type 2 diabetes. N Egl J Med 2001;20;345: Gaede, P, Lud-Aderse H, Parvig HH et al. Effect of a multifactorial itervetio o mortality i type 2 diabetes. N Egl J Med 2008;358: Gaede P, Valetie WJ, Palmer AJ et al. Cost-effectiveess of itesified versus covetioal multifactorial itervetio i type 2 diabetes: results ad projectios from the Steo-2 study. Diab Care 2008;31: Dask Selskab for Alme Medici. Type 2-diabetes i alme praksis. E