Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 147 No. 2728 (2017)

Glycaemic, blood pressure and lipid goal attainment and chronic kidney disease stage of type 2 diabetic patients treated in primary care practices

DOI
https://doi.org/10.4414/smw.2017.14459
Cite this as:
Swiss Med Wkly. 2017;147:w14459
Published
06.07.2017

Summary

INTRODUCTION

The prevalence of chronic kidney disease and diabetes is rising in Europe. These patients are at high cardiovascular and renal risk and need a challenging multifactorial therapeutic approach.

METHOD

The goal of this cross-sectional study was to examine the treatment and attainments of goals related to cardiovascular risk factors within chronic kidney disease stages in type 2 diabetic patients followed up by primary care physicians in Switzerland. Each participating physician entered into a web database the anonymised data of up to 15 consecutive diabetic patients attending her/his office between December 2013 and June 2014. Diabetes, hypertension and lipid lowering therapies were analysed, as well as glycated haemoglobin (HbA1c), blood pressure and low-density lipoprotein-cholesterol (LDL-c) levels and goal attainments by KDIGO chronic kidney disease stage 1 to 4.

RESULTS

A total of 1359 patients (mean age 66.5±12.4 years) were included by 109 primary care physicians. Chronic kidney disease stages 0–2, 3a, 3 b and 4 were present in 77.6%, 13.9%, 6.1%, and 2.4%, respectively. Average HbA1c was independent of chronic kidney disease stage and close to 7%; more than half of the patients reached the HbA1c goal. Eighty-four percent of patients were hypertensive and only 18.2% reached the then current Swiss or American Diabetes Association 2013 blood pressure goals. Despite loosening of blood pressure goals in 2015, only half of the patients reached them and most needed multiple therapies. Increased body mass index and advanced chronic kidney disease stage decreased the chance of reaching blood pressure goals. Lipid lowering therapy was prescribed in 62.1% of cases, with average LDL-c levels similar across chronic kidney disease stages. Only 42% of patients reached the LDL-c goal of <2.5 mmol/l in primary prevention and 32% reached <1.8 mmol/l in secondary prevention. Younger patients were treated significantly less aggressively than older patients (≥68 years, median age) for HbA1c, LDL-c and diastolic blood pressure control.

CONCLUSION

This cross-sectional study demonstrates that blood pressure and lipid goals are less often achieved than blood glucose control in type 2 diabetic patients followed up by primary care physicians in Switzerland. Goal attainments for HbA1c and LDL-c were not influenced by chronic kidney disease stages, in contrast to blood pressure. Reaching all three goals was rare (2.2%). There is a need for improvement in blood pressure control in advanced chronic kidney disease, whereas HbA1c goals may be loosened in the elderly and in advanced chronic kidney disease.

References

  1. American Diabetes Association. (6) Glycemic targets. Diabetes Care. 2015;38(Suppl_1):S33–40. https://doi.org/10.2337/dc15-S009
  2. American Diabetes Association. (8) Cardiovascular disease and risk management. Diabetes Care. 2015;38(Suppl_1):S49–57. https://doi.org/10.2337/dc15-S011
  3. Rydén L, Grant PJ, Anker SD, Berne C, Cosentino F, Danchin N, et al. the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD). ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2013;34(39):3035–87. Available at:.https://doi.org/10.1093/eurheartj/eht108
  4. National Kidney Foundation. KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 Update. Am J Kidney Dis. 2012;60(5):850–86. https://doi.org/10.1053/j.ajkd.2012.07.005
  5. KDIGO Board. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2013;3(1, suppl):1–150.
  6. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348(5):383–93. https://doi.org/10.1056/NEJMoa021778
  7. Rao DT, Sunio LK, Lo YJ, Gossain VV. Comparison of the adherence to the american diabetes association guidelines of diabetes care in primary care and subspecialty clinics. J Diabetes Metab Disord. 2015;14(1):35. https://doi.org/10.1186/s40200-015-0158-x
  8. De Cosmo S, Viazzi F, Pacilli A, Giorda C, Ceriello A, Gentile S, et al.; AMD-Annals Study Group. Achievement of therapeutic targets in patients with diabetes and chronic kidney disease: insights from the Associazione Medici Diabetologi Annals initiative. Nephrol Dial Transplant. 2015;30(9):1526–33. https://doi.org/10.1093/ndt/gfv101
  9. Metsärinne K, Bröijersen A, Kantola I, Niskanen L, Rissanen A, Appelroth T, et al.; STages of NEphropathy inType 2 Diabetes Study Investigators. High prevalence of chronic kidney disease in Finnish patients with type 2 diabetes treated in primary care. Prim Care Diabetes. 2015;9(1):31–8. https://doi.org/10.1016/j.pcd.2014.06.001
  10. Leiter LA, Berard L, Bowering CK, Cheng AY, Dawson KG, Ekoé JM, et al. Type 2 diabetes mellitus management in Canada: is it improving? Can J Diabetes. 2013;37(2):82–9. https://doi.org/10.1016/j.jcjd.2013.02.055
  11. Lamine F, Lalubin F, Pitteloud N, Burnier M, Zanchi A. Chronic kidney disease in type 2 diabetic patients followed-up by primary care physicians in Switzerland: prevalence and prescription of antidiabetic drugs. Swiss Med Wkly. 2016;146:w14282.
  12. American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care. 2013;36(Suppl 1):S11–66. https://doi.org/10.2337/dc13-S011
  13. Swiss Society of Hypertension (SSH). Guidelines 2009; http://www.swisshypertension.ch/guidelines.htm.
  14. Fox CS, Golden SH, Anderson C, Bray GA, Burke LE, de Boer IH, et al.; American Heart Association Diabetes Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Clinical Cardiology, Council on Cardiovascular and Stroke Nursing, Council on Cardiovascular Surgery and Anesthesia, Council on Quality of Care and Outcomes Research; American Diabetes Association. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association. Diabetes Care. 2015;38(9):1777–803. https://doi.org/10.2337/dci15-0012
  15. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159–219. https://doi.org/10.1093/eurheartj/eht151
  16. Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, et al. European Association for Cardiovascular Prevention & Rehabilitation; ESC Committee for Practice Guidelines (CPG) 2008-2010 and 2010-2012 Committees. ESC/EAS Guidelines for the management of dyslipidaemias: the Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J. 2011;32(14):1769–818. Available at:.https://doi.org/10.1093/eurheartj/ehr158
  17. Cuzick J. A Wilcoxon-type test for trend. Stat Med. 1985;4(1):87–90. https://doi.org/10.1002/sim.4780040112
  18. Kainz A, Hronsky M, Stel VS, Jager KJ, Geroldinger A, Dunkler D, et al. Prediction of prevalence of chronic kidney disease in diabetic patients in countries of the European Union up to 2025. Nephrol Dial Transplant. 2015;30(Suppl 4):iv113–8. https://doi.org/10.1093/ndt/gfv073
  19. Bilo H, Coentrao L, Couchoud C, Covic A, De Sutter J, Drechsler C, et al.; Guideline development group. Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant. 2015;30(Suppl 2):ii1–142. https://doi.org/10.1093/ndt/gfv100
  20. Frei A, Herzog S, Woitzek K, Held U, Senn O, Rosemann T, et al. Characteristics of poorly controlled Type 2 diabetes patients in Swiss primary care. Cardiovasc Diabetol. 2012;11(1):70. https://doi.org/10.1186/1475-2840-11-70
  21. Kaiser A, Vollenweider P, Waeber G, Marques-Vidal P. Prevalence, awareness and treatment of type 2 diabetes mellitus in Switzerland: the CoLaus study. Diabet Med. 2012;29(2):190–7. https://doi.org/10.1111/j.1464-5491.2011.03422.x
  22. Bodmer M, Meier C, Krähenbühl S, Jick SS, Meier CR. Metformin, sulfonylureas, or other antidiabetes drugs and the risk of lactic acidosis or hypoglycemia: a nested case-control analysis. Diabetes Care. 2008;31(11):2086–91. https://doi.org/10.2337/dc08-1171
  23. Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, Davis M, et al., Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86. https://doi.org/10.1056/NEJM199309303291401
  24. de Boer IH, Rue TC, Cleary PA, Lachin JM, Molitch ME, Steffes MW, et al., Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study Research Group. Long-term renal outcomes of patients with type 1 diabetes mellitus and microalbuminuria: an analysis of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications cohort. Arch Intern Med. 2011;171(5):412–20. https://doi.org/10.1001/archinternmed.2011.16
  25. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837–53. https://doi.org/10.1016/S0140-6736(98)07019-6
  26. Ismail-Beigi F, Craven T, Banerji MA, Basile J, Calles J, Cohen RM, et al.; ACCORD trial group. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet. 2010;376(9739):419–30. https://doi.org/10.1016/S0140-6736(10)60576-4
  27. Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, et al., ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358(24):2560–72. https://doi.org/10.1056/NEJMoa0802987
  28. de Boer IH, Sun W, Cleary PA, Lachin JM, Molitch ME, Steffes MW, et al., DCCT/EDIC Research Group. Intensive diabetes therapy and glomerular filtration rate in type 1 diabetes. N Engl J Med. 2011;365(25):2366–76. https://doi.org/10.1056/NEJMoa1111732
  29. Shurraw S, Tonelli M. Intensive glycemic control in type 2 diabetics at high cardiovascular risk: do the benefits justify the risks? Kidney Int. 2013;83(3):346–8. https://doi.org/10.1038/ki.2012.431
  30. Wong MG, Perkovic V, Chalmers J, Woodward M, Li Q, Cooper ME, et al.; ADVANCE-ON Collaborative Group. Long-term Benefits of Intensive Glucose Control for Preventing End-Stage Kidney Disease: ADVANCE-ON. Diabetes Care. 2016;39(5):694–700. https://doi.org/10.2337/dc15-2322
  31. Wanner C, Inzucchi SE, Lachin JM, Fitchett D, von Eynatten M, Mattheus M, et al.; EMPA-REG OUTCOME Investigators. Empagliflozin and Progression of Kidney Disease in Type 2 Diabetes. N Engl J Med. 2016;375(4):323–34. https://doi.org/10.1056/NEJMoa1515920
  32. Heerspink HJ, Perkins BA, Fitchett DH, Husain M, Cherney DZ. Sodium Glucose Cotransporter 2 Inhibitors in the Treatment of Diabetes Mellitus: Cardiovascular and Kidney Effects, Potential Mechanisms, and Clinical Applications. Circulation. 2016;134(10):752–72. https://doi.org/10.1161/CIRCULATIONAHA.116.021887
  33. Miller ME, Bonds DE, Gerstein HC, Seaquist ER, Bergenstal RM, Calles-Escandon J, et al.; ACCORD Investigators. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study. BMJ. 2010;340(jan08 1):b5444. https://doi.org/10.1136/bmj.b5444
  34. Bonds DE, Miller ME, Bergenstal RM, Buse JB, Byington RP, Cutler JA, et al. The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study. BMJ. 2010;340(jan08 1):b4909. https://doi.org/10.1136/bmj.b4909
  35. McCoy RG, Van Houten HK, Ziegenfuss JY, Shah ND, Wermers RA, Smith SA. Increased mortality of patients with diabetes reporting severe hypoglycemia. Diabetes Care. 2012;35(9):1897–901. https://doi.org/10.2337/dc11-2054
  36. Burnier M, Gasser UE. End-digit preference in general practice: a comparison of the conventional auscultatory and electronic oscillometric methods. Blood Press. 2008;17(2):104–9. https://doi.org/10.1080/08037050801972881
  37. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009;338(may19 1):b1665. https://doi.org/10.1136/bmj.b1665
  38. Bangalore S, Kumar S, Lobach I, Messerli FH. Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and bayesian random-effects meta-analyses of randomized trials. Circulation. 2011;123(24):2799–810, 9, 810. https://doi.org/10.1161/CIRCULATIONAHA.110.016337
  39. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317(7160):703–13. https://doi.org/10.1136/bmj.317.7160.703
  40. Zoungas S, de Galan BE, Ninomiya T, Grobbee D, Hamet P, Heller S, et al.; ADVANCE Collaborative Group. Combined effects of routine blood pressure lowering and intensive glucose control on macrovascular and microvascular outcomes in patients with type 2 diabetes: New results from the ADVANCE trial. Diabetes Care. 2009;32(11):2068–74. https://doi.org/10.2337/dc09-0959
  41. Bakris GL, Weir MR, Shanifar S, Zhang Z, Douglas J, van Dijk DJ, et al., RENAAL Study Group. Effects of blood pressure level on progression of diabetic nephropathy: results from the RENAAL study. Arch Intern Med. 2003;163(13):1555–65. https://doi.org/10.1001/archinte.163.13.1555
  42. Chapter 4: Blood pressure management in CKD ND patients with diabetes mellitus. Kidney Int Suppl (2011). 2012;2(5):363–9. https://doi.org/10.1038/kisup.2012.54
  43. Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al.; Collaborative Study Group. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345(12):851–60. https://doi.org/10.1056/NEJMoa011303
  44. Bakris GL, Sarafidis PA, Weir MR, Dahlöf B, Pitt B, Jamerson K, et al.; ACCOMPLISH Trial investigators. Renal outcomes with different fixed-dose combination therapies in patients with hypertension at high risk for cardiovascular events (ACCOMPLISH): a prespecified secondary analysis of a randomised controlled trial. Lancet. 2010;375(9721):1173–81. https://doi.org/10.1016/S0140-6736(09)62100-0
  45. Roas S, Bernhart F, Schwarz M, Kaiser W, Noll G. Antihypertensive combination therapy in primary care offices: results of a cross-sectional survey in Switzerland. Int J Gen Med. 2014;7:549–56.
  46. Stemer G, Zehetmayer S, Lemmens-Gruber R. Evaluation of risk factor management of patients treated on an internal nephrology ward: a pilot study. BMC Clin Pharmacol. 2009;9(1):15. https://doi.org/10.1186/1472-6904-9-15
  47. Bally K, Martina B, Halter U, Isler R, Tschudi P. Barriers to Swiss guideline-recommended cholesterol management in general practice. Swiss Med Wkly. 2010;140(19-20):280–5.
  48. Fox CS, Matsushita K, Woodward M, Bilo HJ, Chalmers J, Heerspink HJ, et al.; Chronic Kidney Disease Prognosis Consortium. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis. Lancet. 2012;380(9854):1662–73. https://doi.org/10.1016/S0140-6736(12)61350-6
  49. Tonelli M, Muntner P, Lloyd A, Manns BJ, Klarenbach S, Pannu N, et al.; Alberta Kidney Disease Network. Risk of coronary events in people with chronic kidney disease compared with those with diabetes: a population-level cohort study. Lancet. 2012;380(9844):807–14. https://doi.org/10.1016/S0140-6736(12)60572-8
  50. Baigent C, Landray MJ, Reith C, Emberson J, Wheeler DC, Tomson C, et al.; SHARP Investigators. The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial. Lancet. 2011;377(9784):2181–92. https://doi.org/10.1016/S0140-6736(11)60739-3
  51. Wanner C, Tonelli M ; Kidney Disease: Improving Global Outcomes Lipid Guideline Development Work Group Members. KDIGO Clinical Practice Guideline for Lipid Management in CKD: summary of recommendation statements and clinical approach to the patient. Kidney Int. 2014;85(6):1303–9. https://doi.org/10.1038/ki.2014.31
  52. Tonelli M, Wanner C ; Kidney Disease: Improving Global Outcomes Lipid Guideline Development Work Group Members. Lipid management in chronic kidney disease: synopsis of the Kidney Disease: Improving Global Outcomes 2013 clinical practice guideline. Ann Intern Med. 2014;160(3):182–9. https://doi.org/10.7326/M13-2453
  53. Tancredi M, Rosengren A, Svensson AM, Kosiborod M, Pivodic A, Gudbjörnsdottir S, et al. Excess Mortality among Persons with Type 2 Diabetes. N Engl J Med. 2015;373(18):1720–32. https://doi.org/10.1056/NEJMoa1504347

Most read articles by the same author(s)

1 2 > >>