1. The extent of albuminuria in individuals with diabetes within Heart of Birmingham PCT Mark Jesky Research Registrar

2. Background Most management of diabetes (and microalbuminuria) takes place in primary care Factors associated with development and progression of nephropathy well established – Good glycaemic control – Blood pressure management – ACEi/ ARB as antihypertensive agents of choice CKD frequently under-recognised Nephrology input later in course of disease

3. Background HoB PCT – Young, ethnically diverse population – has the highest take up rate of renal replacement therapy within UK – Enhanced, electronic recording of individuals ≥40 years or identified as having a vascular disease Gain insight into practice within primary care setting

4. NICE CKD Guidelines: Diabetes

5. Audit Questions What is the extent of albuminuria within primary care diabetic population? Are NICE CKD guidelines being followed? – checking eGFR and ACR at least annually – if ACR elevated, are ACEi/ARBs being prescribed? Are any factors (age, gender, ethnicity) associated with not having ACR performed?

6. Diabetes and Measurement of Renal function June 2011 extract 21,529 classified as diabetic – HoB population ≈ 300,000 – 7.2% Of those 21,529, within last 12 months – 69.0% (14,854) had an eGFR recorded – 69.0% (14,857) had an ACR recorded 62.5% in National diabetes audit 2010 ~50% National diabetes audit 2008 – 51.2% (11,033) have both eGFR and ACR

7. Degree of Albuminuria n=Normo- albuminura Micro- albuminuria Macro- albuminuria Male76325204 (68.2%) 1982 (26.0%) 446 (5.8%) Female72255493 (76.0%) 1375 (19.0%) 367 (5.1%) Combined1485710697 (72.0%) 3357 (22.6%) 803 (5.4%) National Diabetes Audit73.5%19.1%7.4% 4140 (28%) diabetic individuals in HoB PCT have some degree of albuminuria

8. Adherence to NICE guidelines (Both ACR and eGFR reported) eGFR ≥ 60eGFR 30 -59eGFR <30 No Albuminuria ACR ≤ 2.5 (M), ACR ≤ 3.5 (F) 6335 (57.4%) 1439 (13.3%) 63 (0.57%) Albuminuria ACR > 2.5 (M), ACR > 3.5 (F) 1963 (17.8%) 1017 (9.2%) 216 (2.0%)

9. Adherence to NICE guidelines (Both ACR and eGFR reported) eGFR ≥ 60eGFR 30 -59eGFR <30 No Albuminuria ACR ≤ 2.5 (M), ACR ≤ 3.5 (F) 6335 (57.4%) 1439 (13.3%) 63 (0.57%) Albuminuria ACR > 2.5 (M), ACR > 3.5 (F) 1963 (17.8%) 1017 (9.2%) 216 (2.0%) 42.6% have either albuminuria or moderate CKD c.f. 45% in National Diabetes Audit

10. Adherence to NICE guidelines ACEi/ ARB usage eGFR ≥ 60eGFR 30 -59eGFR <30 No Albuminuria ACR ≤ 2.5 (M), ACR ≤ 3.5 (F) 6335 (57.4%) 1439 (13.3%) 63 (0.57%) Albuminuria ACR > 2.5 (M), ACR > 3.5 (F) 1963 (17.8%) 1017 (9.2%) 216 (2.0%) Of these 2980, 68.2% (2032) on ACEi/ARB, 31.8% (948) not

11. Checking ACR Demonstrated ACR not consistently checked Can any factors associated with this be identified?

12. Checking ACR ACR measuredACR not measured Gender (% female)48.6(100)50.6(100) Age (years)61.0(100)58.6(100) Systolic BP (mmHg)132.6(97.9)132.4(93.3) Diastolic BP (mmHg)76.0(99.8)76.6(96.1) HbA1c (%)7.6(96.9)7.7(93.0) eGFR (% <60ml/min)32.7(76.3)21.1(69.0) Bangladeshi (%) 72.327.7 Black (%) 72.827.2 Indian (%) 72.427.6 Pakistani (%) 64.435.6 White (%) 68.931.1 Not Stated (%) 67.532.5

13. Checking ACR ACR measuredACR not measured Gender (% female)48.6(100)50.6(100) Age (years)61.0(100)58.6(100) Systolic BP (mmHg)132.6(97.9)132.4(93.3) Diastolic BP (mmHg)76.0(99.8)76.6(96.1) HbA1c (%)7.6(96.9)7.7(93.0) eGFR (% <60ml/min)32.7(76.3)21.1(69.0) Bangladeshi (%) 72.327.7 Black (%) 72.827.2 Indian (%) 72.427.6 Pakistani (%) 64.435.6 White (%) 68.931.1 Not Stated (%) 67.532.5

14. Audit Questions What is the extent of albuminuria within primary care diabetic population? Are NICE CKD guidelines being followed? – checking eGFR and ACR at least annually – if ACR elevated, are ACEi/ARBs being prescribed? Do any factors (age, gender, ethnicity) predispose to not having tests done?

15. Summary ACR assessed in under 70% diabetic population Just over half had ACR and eGFR recorded in last 12 months ACEi/ ARB usage not as extensive as should be People with ACR not checked tend to be – Younger – Pakistani, White, ethnicity not stated – Less likely to have eGFR <60 – Less likely to have other parameters checked Implications for risk stratification More can be done to try to reduce rate of progression in this high risk population

16. Acknowledgements Amanda Lambert Dr Felix Burden Dr Paul Cockwell