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Low Adherence to Guidelines for Nephropathy and Hypertension in Diabetics

Most patients with Type 2 diabetes are not receiving care as per the ADA guidelines released in 2004 for diabetic nephropathy. Patients with hypertension and diabetes have a 5- to 6-fold greater risk of end-stage renal disease compared to patients with hypertension and no diabetes, according to Marlene Sigwalt, RN, MSPH, researcher, Humana Inc., Louisville, Kentucky.

To determine the level of compliance with the 2002 ADA diabetic nephropathy guidelines, Ms. Sigwalt and associates evaluated medical or pharmacy claims made in 2001 by members of a large fee-for-service health plan who had hypertension and type 2 diabetes.

"Until now, the extent to which type 2 diabetics receive guideline-directed preventive renal care has not been known," according to Ms. Sigwalt.

They identified 4262 patients with both hypertension and type 2 diabetes; of these, 31.3% did not have claims for either an angiotensin-converting enzyme (ACE)-inhibitor or an angiotensin receptor blocker (ARB), and 29.8% had either a claim for a protein urine check or a nephropathy diagnosis.

Of 120 protein urine test results available, 69.2% had normal albuminuria, 23.3% had microalbuminuria, and 7.5% had macroalbuminuria.

Of 111 patients whose laboratory values reflected normal or microalbuminuria, 67% were being treated with an ACE-inhibitor or ARB. In the 465 patents who had a diagnosis of nephropathy, 24.5% were being treated with an ARB in accordance with the 2002 and ADA recommendations.

Control of high blood pressure coupled with close monitoring for nephropathy may thwart the onset of nephropathy in these patients, and conscientious adherence to the ADA guidelines is crucial, Ms. Sigwalt said. More aggressive use of ARBs to deter the progression of nephropathy is also important, she added.

In 2002, the ADA issued new standards of medical care for diabetic patients, as well as recommendations for the treatment of hypertension in adults with diabetes, and for detection, prevention, and treatment of diabetic nephropathy.

The ADA diabetic nephropathy guidelines, plus an expert consensus of the American Medical Association, the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance, state that all patients with type 2 diabetes should undergo annual testing for presence of microalbuminuria, starting at diagnosis.

In addition, ARBS and ACE-inhibitors are the initial agents of choice in patients with type 2 diabetes and hypertension who also have microalbuminuria or clinical albuminuria.


November 1st at the 37th Annual Meeting of the American Society of Nephrology. Abstract Title: "Persons With Hypertension and Type 2 Diabetes Are not Receiving Care Per ADA Diabetic Nephropathy Guidelines." Abstract SU-PO187]

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