A Quality Improvement Model for Optimizing Care of the Diabetic End‐Stage Renal Disease Patient

Abstract

Persons with diabetes mellitus whose kidney disease progresses to end-stage requiring dialysis have poorer outcomes compared to nondiabetic patients who commence maintenance dialysis. In the diabetic patient without renal failure, sustained strict glycemic, lipid, and blood pressure (BP) control can retard or thwart diabetic complications such as retinopathy, neuropathy, coronary disease, and peripheral vascular disease. Achieving these outcomes requires multidisciplinary collaborative care. Best care of the diabetic person requires a dedicated clinician who knows the patient well, who closely follows the course of clinical problems, who provides frequent assessments and interventions, and who also directs care to other agencies, clinics, and specialized clinicians who provide expert focused evaluations and interventions aimed at specific clinical concerns. Diabetic patients who reach end-stage renal disease (ESRD) have even greater clinical need of a dedicated principal care clinician than the diabetic patient who has minimal or moderate kidney disease. The diabetic patient with ESRD exhibits greater fluctuations in glucose and BP due to dialysis-related diet patterns and fluid balances and has more active cardiovascular problems due to the combined influences of calcium, phosphorus, and lipid imbalances. These problems warrant exceptional care that includes frequent surveillance and monitoring with timely interventions if patient outcomes are to be improved. We present here a quality improvement model for optimizing care of the diabetic dialysis patient that relies on a dedicated practitioner who can evaluate and intervene on the multiple variables within and beyond the dialysis clinic that impact the patient's health. We present three detailed clinical care pathways that the dedicated clinician can follow. We believe that patient outcomes can be improved with this approach that provides customized problem-focused care, collaborates with the dialysis-provider team, and extends and directs diabetic self-care, home-care, and specialized clinical care in the challenging areas of cardiac and peripheral vascular disease, glycemic control, lipid control, infection prevention, and BP management.

Impact of Diabetes Mellitus on Survival in Patients with End-Stage Renal Disease: A Three-Year Follow-Up

“…Recently published data revealed 24% mortality attributed to sudden cardiac death in 230 ESRD patients in a 5-year study [8] . Hospital admissions for diabetic ESRD patients are 26% more frequent compared with others, particularly for cardiovascular (27%) causes [9] . More diabetics were hospitalized due to cardiovascular causes in our group (p = 0.031).…”

Models of care for co‐morbid diabetes and chronic kidney disease

“…Previously, proposed models of health‐care for co‐morbid diabetes and CKD have not been co‐designed with key stake‐holders or formally evaluated. They have been derived either from clinical experience, or through the deductive synthesis and extrapolation of evidence from literature pertaining to the care of diabetes, CKD and/or other chronic conditions . Common themes and elements drawn from these proposed models of care include multidisciplinary specialist teams and care; quality improvement strategies; effective communication and coordination of care especially across the primary/specialist care interface; and patient education including support for self‐management …”

“…They have been derived either from clinical experience, or through the deductive synthesis and extrapolation of evidence from literature pertaining to the care of diabetes, CKD and/or other chronic conditions. [16][17][18] Common themes and elements drawn from these proposed models of care include multidisciplinary specialist teams and care; quality improvement strategies; effective communication and coordination of care especially across the primary/specialist care interface; and patient education including support for selfmanagement. [16][17][18] However, there are several studies demonstrating the effectiveness of particular components of health-care: interventions that: are structured, intensive and multifaceted; involve multiple medical disciplines (multi-disciplinary); improve patient self-management; and upskill primary health-care.…”

Comparative Study of Three Traditional Mongolian Medicines on Streptozotocin-induced Diabetic Nephropathy in Rats

“…Mesangial expansion and the degree of tubulointerstitial fibrosis correlate inversely with glomerular filtration rate (GFR) in humans with diabetic kidney disease and appear to be critical steps in the progression of diabetic nephropathy to end-stage renal disease [4,5]. Although many therapies have been tested in animal models, and have yielded significant efficacy for DN, translating these experimental therapies to humans is enormously challenging [6]. Endogenous circadian rhythm could enable living species to acquire some independence in relation to time.…”