HbA1c in a primary care cohort with diabetes and chronic kidney disease: the East and North Hertfordshire Institute of Diabetes and Endocrinology (ENHIDE) Diabetes Renal Telehealth Project

Peter H Winocour, Karen Moore-Haines, Keith Sullivan, Anne Currie, Andrew Solomon, Dawn Hardy

Abstract


Aim: Diabetes mellitus and chronic kidney disease (CKD) commonly co-occur. Control of glycaemia is nuanced, and should be individualised. The Diabetes Renal Telehealth Project identified 2,356 adults with diabetes and CKD, and evaluated determinants and patterns of HbA1c in order to identify under-treatment or potential over-treatment of glycaemia.

Method: Comprehensive review of GP diabetes registers by the clinical investigators.

Results: The study subjects (52% male, 48% female) were aged 77 years (range 19–103) with median estimated glomerular filtration rate 52 (range 3–171) mL/min and median albumin to creatinine ratio 34 (range <0.05–1428) mg/mmol. 81% were solely managed in primary care. Median HbA1c was 57 (range 10–148) mmol/mol (7.4% (3.1–15.7%)) and at the 58 mmol/mol target in 64%. Anaemia was present in 31%. 22% were solely on dietary management, 29% on insulin therapy (6 in 10 of whom were also on additional agents) and 19% were on sulfonylurea (8 in 10 of whom were on additional agents excluding insulin). Patterns of HbA1c over 2 years were stable for 44%, variable in 19%, rising in 12% and improved in 8%. The 13% initially considered at increased hypoglycaemic risk based on HbA1c measures alone had worse renal function and were more frequently anaemic (both p<0.0005), and 83% were treated with insulin and/or sulfonylureas. Hypoglycaemia hospital admissions were low with 10 people admitted over the study period. There was a reduction in age with increasing quintiles of HbA1c, and those with HbA1c >75 mmol/mol (9.0%) were youngest (mean age 68 years, p<0.001).

Conclusions: The majority of people with diabetes and CKD are elderly and managed in primary care, with anaemia in 31%, potentially affecting HbA1c interpretation. Iatrogenic hypoglycaemic risk was identified in 10%, with suboptimal glycaemic control (HbA1c >9% (75 mmol/mol)) through under-treatment in 9%. This study uncovered unmet clinical need, requiring both escalation and de-escalation of glycaemic therapies.

 


Keywords


diabetes, chronic kidney disease (CKD), glycaemia, haemoglobin A1c, anaemia, hypoglycaemia, ageing

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References


Steenkamp R, Caskey F. UK Renal Registry 18th Annual Report: Chapter 6. Comorbidities and current smoking status amongst patients starting renal replacement therapy in England, Wales and Northern Ireland from 2013 to 2014. Nephron 2016;132 (suppl 1):145-154. http://dx.doi.org/10.1159/000444820

Ellam T, Twohig H, Khwaja A. Chronic kidney disease in elderly people: disease or disease label. BMJ 2016 352:h6559 https://doi.org/10.1136/bmj.h6559

Hill CJ, Cardwell CR, Maxwell AP, et al. Obesity and kidney disease in type 1 and type 2 diabetes: an analysis of the National Diabetes Audit. Q J Med 2013;106 :933-942. https://doi.org/10.1093/qjmed/hct123

KDOQI (Kidney Disease Outcomes Quality Initiative) Clinical practice guideline for diabetes and CKD: 2012 update. Am J Kid Dis 2012;60: 850–886.

Winocour PH .Diabetes and chronic kidney disease: an increasingly common multi-morbid disease in need of a paradigm shift in care. . Diabetic Med, 2018; 35, 300–305 https://doi.org/10.1111/diabetese.13564

Shurraw S, Hemmelgarn B, Lin M, et al. Association between Glycemic Control and Adverse Outcomes in People with Diabetes Mellitus and Chronic Kidney Disease. Arch Intern Med 2011; 171:1920-1927

Papademetriou V, Lovato L, Doumas M, et al. Chronic kidney disease and intensive glycaemic control increase cardiovascular risk in patients with type 2 diabetes. Kidney Int 2015; 87: 649–659.

Borg R, Persson F , Siersma V, et al. Interpretation of HbA1c in primary care and potential influence of anaemia and chronic kidney disease : an analysis from the Copenhagen Primary care Laboratory (CopLab) Database . Diabet Med 2018; 35: 1700-1706

English E , Idris I, Smith G, et al. The effect of anaemia and abnormalities of erythrocyte indices on HbA1c analysis: a systematic review. Diabetologia 2015; 58: 1409-1421

Raja UY, Chan J, Radford E, et al. The prevalence of anaemia in diabetes with stage 3 chronic kidney disease: a retrospective analysis. Br J Diabetes Vasc Dis 2011; 11: 259–261.

Inoue K , Goto A , Kishimoto M , et al. Possible discrepancy of HbA1c values and its assessment amongst patients with chronic renal failure, hemodialysis and other diseases. Clin Exp Nephrol 2015; 19: 1179-1183

Ng JM, Cooke M, Bhandari S, et al. The effect of iron and erythropoietin treatment on the A1C of patients with diabetes and chronic kidney disease. Diabetes Care 2010; 33: 2310–2313.

Abdelhafiz AH, Sinclair AJ. Low HbA1c and increased mortality risk – is Frailty a Confounding Factor? Aging Dis 2015;6: 262-270

Alsahi M,Gerich JE. Hypoglycaemia in patients with diabetes and renal disease . J Clin Med 2015; 4: 948-964

Moen M, Zhan M, Hsu V D, et al. Frequency of hypoglycaemia and its significance in chronic kidney disease. Clin J Am Soc Nephrol 2009; 4:1121-7

Davis TME, Brown SGA, Jacobs IG, et al. . Determinants of severe hypoglycaemia complicating type 2 diabetes: The Fremantle Diabetes study. J Clin Endocrinol Metab 2010; 95: 2240-2247 https://doi.org/10.1210/jc.2009-2828

Khunti K, Davies M, Majeed A, et al. . Hypoglycaemia and risk of cardiovascular disease and all-cause mortality in insulin treated people with type 1 and type 2 diabetes : a cohort study Diabetes Care 2015;38: 316-322

Rajendran R, Hodgkinson D, Rayman G. Patients with diabetes requiring emergency department care for hypoglycaemia: characteristics and long term outcomes determined from multiple data sources. Postgrad Med J 2015; 91:65-71

Sampson M , Bailey M , Clark J, et al . A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: The Eastern Academic Health science Network (EAHSN) model. Diabetes Res Clin Pract 2017; 133:50-59

Hambling Ce, Seidu SI, Davies MJ, Khunti K. Older people with type 2 diabetes , including those with chronic kidney disease or dementia , are commonly over treated with sulfonylurea or insulin therapies . Diabetic Med 2017; 34: 1219-1227

Winocour PH , Bain SC, Chowdhury T, De P, et al . Managing hyperglycaemia in patients with diabetes and diabetic nephropathy - chronic kidney disease Summary of recommendations 2018. Br J Diabetes 2018; 18:78-89

Hill CJ, Cardwell CR, Patterson CC, Maxwell AP , et al. Chronic kidney disease and diabetes in the National Health Service: a cross-sectional survey of the UK National Diabetes Audit. Diabetic Med 2014; 31:448-454 https://doi.org/10.1111/diabetese.12312

2019/20 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF) Guidance for GMS contract 2019/20 in England .April 2019. Accessed October 2019 at : https://www.england.nhs.uk/wp-content/uploads/2019/05/gms-contract-qof-guidance-april-2019.pdf

Winocour PH, Moore-Haines K, Solomon A, et al. . ENHIDE Telehealth Primary Care Support of Adults with Diabetes and Chronic Kidney Disease. A pilot study - Rationale and Study Design. Br J Diabetes 2019; 19: 53-62

Accessed at: http://fingertips.phe.org.uk/profile/general-practice

Camargo EG, Soares AA, Detanico AB, et al. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is less accurate in individuals with type 2 diabetes when compared with healthy individuals. Diabet Med. 2011; 28:90-95

Hirst JA, Montes M, Taylor C, et al. Impact of a single eGFR and eGFR-estimating equation on chronic kidney disease reclassification. Br J Gen Pract 2018; 68:524-530

Jones RK, Hampton D, O’Sullivan DJ, Phillips AO. Diabetes and Renal disease: who does what? Clin Med 2013; 13: 460-464 https://doi.org/10.7861/clinmedicine.13-5-460

Khunti K, Gomes MB, Pocock S, et al. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review. Diabetes Obes Metab 2018; 20:427-437

Nair S, Mishra V, Hayden K et al. The four-variable modification of diet in renal disease formula underestimates glomerular filtration rate in obese type 2 diabetic individuals with chronic kidney disease. Diabetologia 2011; 54: 1304–1307.

Wang Y, Katzmarzyk PT, Horswell R, et al. Comparison of the heart failure risk stratification performance of the CKD-EPI equation and the MDRD equation for estimated glomerular filtration rate in patients with type 2 diabetes. Diabet Med 2016; 33: 609–620.

Bello AK, Peters J, Rigby J, et al. Socioeconomic Status and Chronic Kidney Disease at Presentation to a Renal Service in the United Kingdom Clin J Am Soc Nephrol 2008: 3:1316–1323.

Ricks J, Molnar MZ, Kovesdy CP, et al. Glycemic Control and Cardiovascular Mortality in Hemodialysis Patients with Diabetes. A 6-Year Cohort Study. Diabetes Care 2012; 61:708-715




DOI: https://doi.org/10.15277/bjd.2020.252

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