Diabetic kidney disease

Peer group discussion points

As noted, Māori and Pacific people are at greater risk of diabteic nephropathy. 

• In order to manage at-risk groups primary health care organizations need to highlight their presence within the practice.  What process does your practice use to gather this data and how do you keep it up to date? 

• Do you use any of the available standardized auditing tools e.g. Clinical record review self-audit checklists  and practice tools such as the primary health care ethnicity toolkit  to facilitate this? 

• Reducing inequity is fundamental in primary health care.  Seeking ways to best care for vulnerable populations may include exploring funding opportunities, changes in practice systems, connecting with local communities and families to initiate positive change.  Can you identify any potential barriers or unmet needs within your clinic or at an individual level for your “at risk patients” and potential action points for change? 

A full diabetic renal assessment takes into account risk factors, blood pressure, renal testing (ACR, creatinine and eGFR), alongside assessing for the risk of progression.  Within this assessment,  microalbuminuria is an important screening tool for assessing end organ damage due to diabetes. 

• In your experience do you routinely request an ACR as a part of your diabetic work up? If not, have you considered undertaking an audit to identify the frequency of testing and consider systems that could be put into place to increase the uptake of this screening tool? 

• This MedTalk discusses calculating the risk of kidney failure by using validated calculators (such as www.kidneyfailurerisk.com). Have you been using these calculators? Do you think you could use these tools in your clinical practice for patient education?

• Managing the results of a renal assessment is key to improving outcomes. Are you now more confident in managing the significant microalbuminuria? If not, what local guidelines or information sources can you access or refer when having to manage a result?

Patients with diabetic renal disease are often on multiple medications which can have a deleterious effect on renal function. The term “Triple Whammy” has been used to describe group of medications ( ACEi/ARB, a diuretic and a NSAID) that individually or combined can cause acute renal injury.

• Have you identified patients at risk of these medication via an audit or another data evaluating tool? What did it show and what changes have you made as a result? Are patients needing their monitoring intensified or medications re-evaluated? Discuss as a group what alternative management options could be explored. 

• Nonsteroidals are a common pain relief medication which can be bought over the counter. When prescribing diuretics and ACEi/ARBs do you routinely warn your patients not to purchase over the counter non-steroidals? What about a discussion around the different brand names and types of non-steroidals? 

• Can you think of any other common nephrotoxic medications that you need to be aware of when prescribing for patients at risk of acute kidney injury?