Achieving blood pressure control in patients with type 2 diabetes and diabetic renal disease by a nurse-led protocol based clinic

Abstract

Evidence-based management of type 2 diabetic renal disease requires use of angiotensin - converting enzyme inhibitor (ACE inhibitor) inhibitors or angiotensin receptor blockers (ARBs), with strict blood pressure control which is difficult to achieve in standard doctor-led diabetic clinics and we have therefore developed a nurse-led clinic using a therapeutic algorithm. ACE inhibitor or ARB treatment was maximised, and antihypertensive drugs titrated or added to optimise blood pressure control. Patients were seen monthly until target blood pressure was met, and then discharged for review of blood pressure control 12 months later. Of 71 patients completing the programme, 52 (72%) had microalbuminuria, and 19 (28%) nephropathy. ACE inhibitor or ARB usage increased from 66 to 91% at review (p=0.0004). Systolic blood pressure fell from152±21 to 131±18mmHg (p< 0.0001) and diastolic blood pressure from 76±13 to 68±10mmHg (p<0.0001). Microalbuminuria rates fell but estimated glomerular filtration rates rose. Structured nurse-led clinics are useful in the optimisation of treatment for type 2 diabetic patients with renal disease. Br J Diabetes Vasc Dis, 2008, 8: 279—284

Keywords

angiotensin receptor blocker ACE inhibitors blood pressure nurse-led clinic microalbuminuria nephropathy type 2 diabetes

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References

Ukpds Group . Tight blood pressure control and risk of macrovascular and microvascular complications in Type 2 diabetes (UKPDS 38). BMJ 1998;317:703-13.

Joss N. , Ferguson C. , Brown C. et al. Intensified treatment of patients with Type 2 diabetes and overt nephropathy. QJM 97 2004;97:219-27.

Parving HH , Lehnert H. , Brockner-Mortensen J. et al. The effect of irbesartan on the development of diabetic nephropathy in patients with Type 2 diabetes. N Engl J Med 2001;345:870-8.

Lewis EJ , Hunsicker LG , Clarke WR et al. Reno-protective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to diabetes. N Engl J Med 2001;345:851-60.

Barnett AH , Bain SC , Bouter P. et al. Angiotensin receptor blockade versus converting enzyme inhibition in type 2 diabetes and nephropathy. N Engl J Med 2004;351:952-61.

Woodward A. , Mugarza J. , Kahn M. et al. Blood pressure control and ACE-I/ARB usage in nephropathic and microalbuminuric Type 2 diabetes. Practical Diabetes International 2008;25:54-8.

Department of Health. Diabetes National Service Framework Strategy . London: DoH, 2002.

European Diabetes Policy Group. A desktop guide to Type 2 diabetes mellitus. Diab Med 1999;16:716-33.

Ramsay LE , Williams B. , Johnston GD et al. Guidelines for management of hypertension: report of the third Working Party of the British Hypertension Society. J Hum Hypertens 1999;13:569-92.

10.

Joint British Societies. JBS 2: Joint British Societies' Guidelines on Prevention of Cardiovascular Disease in Clinical Practice. Heart 2005; 91(suppl V): v1-v52.

11.

American Diabetes Association. Standards of Medical Care in Diabetes -2006. Diab Care 2006;29(suppl 1): S4-S42.

12.

Woodward A. , Wallymahmed M. , Wilding J. , Gill G. Successful cardiovascular risk reduction in Type 2 diabetes by nurse-led care using an open clinical algorithm. Diab Med 2006;23:780-7.

13.

Gaede P. , Lund-Andersen H. , Parving HH , Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes . N Engl J Med 2008;358:580-91.

14.

Steigerwalt S. Management of hypertension in diabetic patients with chronic kidney disease. Diab Spect 2008 ;21:30-36.

15.

Kelly CJG , Booth G. Pharmacist-led structured care for patients with diabetic nephropathy. Br J Diabetes Vasc Dis 2008;8:86-8.

16.

Gale EAM.

The Hawthorne Studies - a fable for our times?

QJM 2004;97: 439-49.

17.

Woodward A. , Wallymahmed M. , Wilding J. , Gill G. Improved glycaemic control: an unintended benefit of a nurse-led cardiovascular risk reduction clinic. Diab Med 2005;22:1272-4.