Download Consultant Diabetologist, King`s College Hospital.

Managing people with CKD & Diabetes:
Setting the Scene.
Prash Vas
Consultant Diabetologist, King’s College Hospital.
Background
• Chronic kidney disease (CKD) - highly prevalent
microvascular complication - 40% of patients with diabetes
develop CKD1.
• People with diabetes are 1.5 times more likely to need renal
replacement therapy (RRT) than peers in the general
population2.
• Carries significant morbidity and mortality.
• Mortality is highest during the first 3 months of
haemodialysis3.
- 27.5 deaths/100 person-years during the first 120 days V 21.9
deaths/100 person-years for days 121–365; p=0.0023.
1 De
Boer IH, et al. JAMA 2011; 305: 2532–2539.
Marshall SM Diab Med 2014 11:1280–1283
3. Ortiz A, Lancet 2014 Vol 383: 1831-1843
2.
Temporal trends in CKD prevalence by race among Medicare patients age
65+, 2000-2012
Data Source: Medicare 5 percent sample.
Source: USRDS
Vol 1, CKD, Ch 2
2
CKD and Socioeconomic deprivation
Bello, Aminu K. et al. CJASN 3.5 (2008): 1316–1323.
3
Social Deprivation is a factor in Diabetes Foot
Development of Foot Ulceration
Likelihood of Amputation
SIMD, Scottish Index of Multiple Deprivation
Leese G, et al, Diab Med (2013) 30:484-490
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How can we provide services to work better
for patients?
Challenges in CKD and Diabetes Management
Pre-Dialysis CKD
Dialysis
Transplant
Pre-Dialysis CKD Challenges
Diabetes
Renal
Pre-Dialysis CKD Challenges
Diabetes
‘Time of major change’
•
Metformin usually stopped
•
HbA1C +++ usually
•
Many require Insulin start
•
CI to use of new anti-diabetic drugs
Compliance
Many T2DM do not even test
Education
Ensuring foot and eye checks
Renal
Pre-Dialysis CKD Challenges
Diabetes
Renal
‘Time of major change’
HTN Control
•
Metformin usually stopped
• Often require multiple drugs
•
HbA1C +++ usually
• Difficult to achieve targets
•
Many require Insulin start
•
CI to use of new anti-diabetic drugs
Ensuring compliance
Compliance
Ethnicity barriers
Many T2DM do not even test
Education- RRT potential
Education
Ensuring foot and eye checks
•
Many have no symptoms
•
‘What is the fuss?’
Pre-Dialysis CKD Challenges
Joint Challenges
Conflicting messages from teams
(MF use, HTN tabs etc)
Engagement with therapy plans can be varied
Adherence can be a challenge
Many still working- they will need supporting letters etc
Obesity can be a challenge
‘Local complexities’
Dialysis Group Challenges
Diabetes
Renal
Dialysis Group Challenges
Diabetes
Many experience Hypoglycaemia
Meals fitted around dialysis
schedules
Weight loss , cachexia
Often have advanced retinopathy
Foot complications++
Neuropathic pain management
Renal
Dialysis Group Challenges
Diabetes
Renal
Many experience Hypoglycaemia
Dialysis Targets
Meals fitted around dialysis
schedules
3 days a week in hospital
Weight loss , cachexia
Often have advanced retinopathy
Foot complications++
Neuropathic pain management
Ensuring adherence
Transplant workup
Infection
Hospital admissions
Dialysis Group Challenges
Joint Challenges
Significant CVD risk
Concept that dialysis patients get all their care during dialysis
sessions (blurring of 1° v 2° care)
Multiple visits to hospital to visit specialties
Patients may call up DM/Renal units with all their problems
Depression and cognition
Loneliness, mobility issues
TRANSPORT
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Transplant Group Challenges
Diabetes
Hyperglycaemia
Hypoglycaemia
Complications of Diabetes do not
improve
Renal
Transplant Group Challenges
Diabetes
Renal
Hyperglycaemia
Immunosuppressant adherence
Hypoglycaemia
Infection
Complications of Diabetes do not
improve
Risk of skin and solid organ
tumours
Multiple visits to hospital
Transplant Group Challenges
Joint Challenges
Depression- Psychosocial impact
Engagement
Weight gain
Multiple visits to hospital for different specialties when
complications set in
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How can we provide services to work better
for patients?
How can we provide a better service?
Pre-Dialysis CKD
Low Clearance clinic and Diabetes Clinic at the same time (same place)
Named Renal and Diabetes Physician, named nurse to contact
Diabetes Led clinics with Renal in reach
Renal Led with Diabetes Specialist Nurse linked in
Supporting GP practices to manage CKD in primary care - UPSKILL
 Community Nephrology clinic
Community Diabetes Clinics
Joint Clinics - GP/Renal/Diabetes
Motivational Training experience for all those involved
How can we provide a better service?
Dialysis
Motivational Training experience for all care givers
Ongoing patient Education
Encouragement
Patient Care while on the machine
Diabetes specialist Inreach into dialysis unit
Diabetes Foot Inreach- foot checks
?Cardiac/Gastro Inreach clinics
Psychological Support – whilst on the machine
Renal Physicians may need to ‘drive the agenda’ ( which clinic etc)
 Medications- How best to work around the patient
Better links with transport and parking tickets/meals during dialysis
How can we provide a better service?
Transplant
Motivational Training experience for all those involved
Patient Education
Joint Diabetes and Transplant Follow Up appointments
Care coordination
Psychological Support
i3-diabetes Project:
A programme to co-create a new, world-class model of
patient-centred, specialist diabetes care that will meet the
changing needs of people with diabetes.
This new model will deliver personalised care – including
psychosocial support – that will lead to improved outcomes
for people living with diabetes, and more efficient and
effective ways of providing care.
i3-diabetes is a collaboration between King’s Health Partners and Novo
Nordisk and funded by both organisations
Plan Ahead
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