Awareness and behaviour of European physicians in relation to microalbuminuria and organ damage: an ESH-endorsed survey

How well do general practitioners manage laboratory test results for patients with diabetes mellitus and cardiovascular disease?: A systematic review

Purpose

To evaluate how well general practitioners (GPs) manage and respond to laboratory results for patients with diabetes mellitus (DM) and cardiovascular disease (CVD).

Data sources

MEDLINE, CINAHL, Embase, EBM reviews, ProQuest and Scopus.

Study selection

Peer-reviewed journal articles published between 2000 and 2015 that assessed GPs' management of laboratory results for patients with DM or CVD.

Data extraction

Study design and demographics, laboratory tests and key findings relating to GP management of laboratory results were extracted from studies.

Results of data synthesis

Thirteen articles were included, comprising seven studies which utilized surveys, four observational studies, one cohort study and one randomized controlled trial. Findings indicate that GPs often overestimate the risk of complications associated with DM and CVD based on laboratory results and have unrealistically high expectations regarding the precision of laboratory tests. Considerable variation existed in the use of repeat testing for diagnostic confirmation and in GPs' identification of the difference between two consecutive results required to indicate a change in patient condition. GPs also often failed to initiate appropriate treatment for patients with DM and CVD based on laboratory results. Feedback to GPs about their test ordering patterns and educational messages on laboratory results improved clinical outcomes.

Conclusion

Evidence about how well GPs manage results and its impact on patient outcomes remains weak and inconclusive. This review identified a number of areas where interventions could support GPs to improve the interpretation and management of laboratory test results, including feedback to GPs and educational messages on test result reports.

Early renal abnormalities as an indicator of cardiovascular risk in type 2 diabetes

Accurate assessment of cardiovascular (CV) risk is a prerequisite for devising effective therapeutic strategies in patients with type 2 diabetes (T2DM) as it allows to refine prognosis and treatment targets as well as the cost-benefit ratio for specific pharmacological interventions. The presence of subclinical vascular organ damage plays a well known role in determining overall risk and a wider use of low cost, easy to perform diagnostic tools to stratify CV risk is very much needed. Besides their well known prognostic value for progression to end stage renal disease (ESRD), subclinical renal abnormalities such as microalbuminuria and/or a slight reduction in estimation of glomerular filtration rate (eGFR), have been shown to be powerful, independent predictors of CV diseases in patients with T2DM. Through the combined evaluation of these two biomarkers of chronic kidney disease (CKD), clinicians can usefully and reliably get a perspective on global and CV outcome of their diabetic patients.

Global cardiovascular risk assessment in the management of primary hypertension: the role of the kidney

The knowledge of each patient's global risk profile is a prerequisite for effective therapeutic strategies in primary hypertension. Detecting the presence of subclinical organ damage at the cardiac, vascular, and renal levels is key for stratifying cardiovascular risk and may also be helpful in choosing antihypertensive agents and in monitoring the effectiveness of treatment. A systematic, in-depth search for subclinical organ damage, however, may be difficult to carry out because of logistic and economic problems related to the high prevalence of hypertension in the population. Renal abnormalities such as microalbuminuria and reduction in glomerular filtration rate have proven to be powerful predictors of cardiovascular and renal outcome. Thanks to their relatively low cost and wide applicability, more widespread use of these tests in the diagnostic workup will help detect subsets of patients at greater risk for whom additional preventive and therapeutic treatment is advisable.

Are triplicate urine samples necessary to assess albuminuria?

BACKGROUND/AIMS

Urinary albumin excretion is subject to intra-individual variability. Thus, for research purposes, it is recommended to test three urine samples collected over a short period of time. The objective of our analysis was to check the usefulness of triplicate samples to determine the albuminuric status of diabetic patients.

METHODS

We present the results of the non-planned retrospective analysis of 246 triplicate morning urine samples obtained from 95 type 2 diabetics included in three multinational, randomized, double-blind studies. Albuminuria was determined by immunoturbidimetry on fresh samples in the same central laboratory. Microalbuminuria was defined by a urine albumin to creatinine ratio (UACR) between 2.5 and 25 mg/mmol in males and between 3.5 and 35 mg/mmol in females. Concordance was obtained when the second and/or third sample (UACR2 and UACR3) confirmed the albuminuric status obtained from the first sample (UACR1).

RESULTS

Considering the first samples, 9% were within the normal range, 35% showed microalbuminuria and 56% showed macroalbuminuria. The overall concordance rate was 95%. The log of UACR was highly correlated between samples. Bland-Altman plots expressed in percent variations between two samples confirmed that the mean variation was low (around 8%) but revealed the scattering of values, 95% being between -60 and +77% of variation between samples.

CONCLUSIONS

There is no benefit in repeating morning UACR determination in diabetic patients to accurately categorize a subject as having normo-, micro- or macroalbuminuria. However, in order to accurately quantify albuminuria, repeated determinations are required.

Predictors of fatal and nonfatal cardiovascular events in patients with type 2 diabetes mellitus, chronic kidney disease, and anemia: an analysis of the Trial to Reduce cardiovascular Events with Aranesp (darbepoetin-alfa) Therapy (TREAT)

AIMS

This study aims to examine predictors of cardiovascular mortality and morbidity in patients with chronic kidney disease (CKD). Individuals with the triad of diabetes, CKD, and anemia represent a significant proportion of patients with cardiovascular disease and are at particularly high risk for adverse outcomes.

METHODS AND RESULTS

Using Cox proportional hazards models, we identified independent predictors of the composite of cardiovascular death, myocardial infarction, stroke, hospitalization for myocardial ischemia, or heart failure (HF) in 3,847 patients in the TREAT, 961 (25%) of whom experienced this outcome. The predictors (ranked by χ(2) value) were prior HF (hazard ratio [HR] 1.74, 95% CI 1.51-2.01), age (HR 1.03, 95% CI 1.02-1.04 per year), log urine protein/creatinine ratio (HR 1.19, 95% CI 1.13-1.26 per log unit ), C-reactive protein ≥6.6 mg/L (HR 1.44, 95% CI 1.23-1.69, compared with C-reactive protein ≤3.0 mg/L), and abnormal electrocardiogram (HR 1.42, 95% CI 1.21-1.66 ), all P < .0001. Addition of cardiac-derived biomarkers (subset of first 1,000 patients enrolled) significantly enhanced risk estimation, with N-terminal pro B-type natriuretic peptide becoming the highest ranked predictor of outcome (HR 1.30, 95% CI 1.15-1.46 per log unit, P < .001) and troponin T providing additional predictive information. These biomarkers improved risk classification in 17.8% (9.4%-26.2%) of patients.

CONCLUSION

In patients with diabetes, CKD, and anemia, cardiovascular risk is most strongly predicted by age, history of HF, C-reactive protein, urinary protein/creatinine ratio, abnormal electrocardiogram, and 2 specific cardiac biomarkers, serum N-terminal pro B-type natriuretic peptide and troponin T, which are elevated in many. These findings suggest ways to improve cardiovascular risk stratification of patients with predialysis CKD, support the concept of cardiorenal syndrome, and may help target therapy.