The 3rd joint meeting of ABCD and the Renal Association took place on 28 February 2017 at the NEC Birmingham and was attended by 134 delegates, of whom over 50 were junior doctors or allied healthcare professionals who were provided with free registration for the meeting.
The purpose of the meeting was to enable updates in areas of controversy and to premiere the national clinical guidelines for the management of diabetes mellitus in patients with chronic kidney disease (CKD)- diabetic nephropathy.
The opening presentation by Professor Garry John on assessing glycaemic control in patients with diabetes who also have CKD and the impact of anaemia was an important reminder of the challenge of using this analytical test when anaemia supervenes and how both falsely low and high HbA1c values can be seen, depending on the basis for the anaemia. Direct glycaemic measures are an integral requirement for effective assessment of glycaemia, especially when trying to minimise the recognised increased risk of hypoglycaemia. The complex interactions between nutritional management in diabetes and more advanced renal disease were enthusiastically delivered by Nevine el Sherbini, renal specialist dietitian, and as in many areas of diabetes and advanced renal disease, clearly showed the need for effective communication between different members of the team.
The meeting then focused in an extended session of the guidelines on managing lipids, blood pressure and glycaemia in diabetes CKD-nephropathy.
The main points emphasised were that lipid metabolism differs in type 1 and type 2 diabetes, and this is further impacted by differing degrees of renal dysfunction. The new criteria for initiation of statins and the focus on high intensity statins in many cases were presented, along with options for managing statin intolerance and potential roles for other types of hypolipidaemic therapy. Regarding blood pressure (BP) management and renin-angiotensin-aldosterone system (RAAS) blockade, target BPs were suggested as 140/90 unless albuminuria was present (when a target of 130/80 would apply), or in younger patients with type 1 diabetes where age normative BP ranges would be appropriate, or in those aged >75 years where a target BP of 150/90 would be safer and more practical. The role of RAAS blockade by ACE inhibitors and angiotensin receptor blockers above and beyond BP lowering was focused on those with albuminuria. Specific BP guidance on seated interdialytic values at 140/90 was stated for patients on haemodialysis.
The meeting was designed to encourage junior doctors and allied healthcare professionals to attend, and three highly rated posters were selected for oral presentation from colleagues from Derby and London. They reported on the important suggestion of increased arterial stiffness as an independent predictor of renal function decline in patients with type 2 diabetes aged <60; the interesting suggestion that diabetic foot ulcer admissions can lead to a degree of acute kidney injury that may not be reversible, leading to worsening CKD; and evidence that enhanced care between renal and diabetes services can improve patient outcomes in those with end stage renal disease.
Dr Christoph Wanner was our invited overseas speaker who gave an update on the renal outcomes from the EMPA-REG and LEADER CVD safety trials. In addition to the recognition that empagliflozin reduced a range of measures of adverse renal outcomes, further analysis suggested cardiovascular outcomes were more notably reduced in those with renal disease at baseline. The potential mechanism of benefit was discussed, although this would require further research in respect of renal haemodynamics and intrarenal metabolism.
Professor George Tadros reviewed the assessment and prevalence of cognitive issues in diabetes CKD and the importance of collaboration with old age psychiatry in such cases, and the challenge of assessing quality of life in end stage renal disease was addressed by Professor Ken Farrington.
The meeting concluded with a comprehensive review of islet cell and pancreas renal transplantation in diabetes by Professor Peter Friend. Where appropriate, simultaneous kidney and pancreas transplantation resulted in better outcomes. The autoimmune basis for type 1 diabetes persists, as reflected in recurrence in some cases of beta cell dysfunction. There was clear evidence of a reduced mortality risk in these patients compared with those remaining on the HD programme, and microvascular and tentative macrovascular benefits associated with the procedure. The challenging issue of reversibility of hypoglycaemia unawareness as a basis for islet cell transplantation was covered and the need for a longer trial to clarify the potential benefit identified.
Feedback from delegates was very positive. It is hoped to continue this biannual meeting with ongoing collaboration between the ABCD and the Renal Association and the expectation that audit standards and research programmes can be developed.
Correspondence: Dr Peter H Winocour
Consultant Physician and Clinical Director
for Diabetes and Endocrine Services,
Queen Elizabeth II Hospital,
Welwyn Garden City, Hertfordshire, UK
Email: peter.winocour@nhs.net
http://dx.doi.org/10.15277/bjd.2017.129
Br J Diabetes 2017;17:81