Improved management and 10-year outcomes in diabetic kidney disease in routine clinical care.

Aim: To examine the impact of service re-design on management and 10-year outcomes in diabetic kidney disease in a real-world setting. Methods: We established a highly structured, nurse-led diabetic kidney clinic to deliver consistent evidence-based care processes (blood pressure control (BP), glycaemic control (HbA1c), renin-angiotensin-aldosterone (RAAS) blockade, lipid-lowering therapy and smoking cessation) and assessed impact on death, doubling of serum creatinine, new end-stage renal disease (ESRD), new cardiovascular (CV) events and decline in estimated glomerular filtration rate (eGFR). Results: There were 261 patients in the 10-year cohort: 9 case notes were missing and 23 had been destroyed. Our analysis is based on 229 patients for whom we had data (1,799 patient-years of follow-up):28 (12%) had new CV events, 22 (10%) progressed to ESRD (16 dialysis, 3 conservative treatment, 3 transplant) and 87/229 (38%) died. At last assessment, mean BP was 129/70 mmHg, HbA1c 59 mmol/mol (7.6%) and LDL-cholesterol 1.81 mmol/L. Mean rate of eGFR decline was 0.15 mL/min/month. Expressed per 100-patient-years, mortality 4.83, CV events 1.56, doubling serum creatinine 1.72, and ESRD 1.22 compare favourably with landmark trials. Conclusions: A highly structured, nurse-led, diabetic kidney clinic can translate consistent evidence-based care processes into favourable 10-year outcomes in routine clinical care.