Albuminuria screening in children with type 1 diabetes prior to and during the COVID-19 pandemic.

BACKGROUND: Albuminuria is an important risk factor for adverse renal and cardiovascular outcomes in type 1 diabetes (T1D). We sought to describe: (1) adherence to albuminuria screening prior to and during the COVID-19 pandemic and (2) occurrence of abnormal urine albumin-creatinine ratio (ACR) tests in children with T1D. METHODS: This cohort study involved children aged 18 years or younger with T1D followed in the diabetes clinic at a pediatric tertiary center. Data was collected from 2016 to 2020. Adherence was defined by Diabetes Canada (DC) Guidelines for T1D in Children and Adolescents (2018). RESULTS: Of the 165 children who met DC criteria for screening; 88 (32%) were male and the median age at diagnosis was 5.8 years. Twenty-eight (17%) children had not completed a single ACR test, and 30 (18%) completed all eligible ACR tests. Test completion decreased from 66% in 2019 to 45% in 2020. Of the 345 ACR tests completed, 40 (11%) were abnormal (>2.5 mg/mmol) and 29 abnormal ACR tests (72%) were not repeated. CONCLUSION: Adherence to albuminuria screening in this pediatric diabetes clinic is suboptimal with deterioration during the COVID-19 pandemic. Patient/physician and program-level strategies to improve adherence will play an important role in quality improvement. IMPACT: Albuminuria screening is an important part of pediatric diabetes care. In our study, pediatric albuminuria screening adherence was suboptimal at 66% in 2019 and deteriorated during the pandemic to 45% in 2020. Program and patient-level adherence to clinical guidelines and barriers to accessing diabetes care during the pandemic merit further study.

Improving annual albuminuria testing for individuals with diabetes.

BACKGROUND: Annual albuminuria screening detects the early stages of nephropathy in individuals with diabetes. Because early detection of albuminuria allows for interventions that lower the risk of developing chronic kidney disease, guidelines recommend annual testing for all individuals with type 2 diabetes mellitus and for those with type 1 diabetes for at least 5 years. However, at the Eskind Diabetes Clinic at the Vanderbilt University Medical Center, testing occurred less frequently than desired. METHODS: A quality improvement team first analysed the clinic's processes, identifying the lack of a systematic approach to testing as the likely cause for the low rate. The team then implemented two successive interventions in a pilot of patients seen by nurse practitioners in the clinic. In the first intervention, staff used a dashboard within the electronic health record while triaging each patient, pending an albuminuria order if testing had not been done within the past year. In the second intervention, clinic leadership sent daily reminders to the triage staff. A statistical process control chart tracked monthly testing rates. RESULTS: After 6 months, annual albuminuria testing increased from a baseline of 69% to 82%, with multiple special-cause signals in the control chart. CONCLUSIONS: This project demonstrates that a series of simple interventions can significantly impact annual albuminuria testing. This project's success likely hinged on using an existing workflow to systematically determine if a patient was due for testing and prompting the provider to sign a pended order for an albuminuria test. Other diabetes/endocrinology and primary care clinics can likely implement a similar process and so improve testing rates in other settings. When coupled with appropriate interventions to reduce the development of chronic kidney disease, such interventions would improve patient outcomes, in addition to better adhering to an established quality metric.

Long-Term Exposure to Ambient PM2.5 and Increased Risk of CKD Prevalence in China.

BACKGROUND: Fine particulate matter (PM2.5) is an important environmental risk factor for cardiopulmonary diseases. However, the association between PM2.5 and risk of CKD remains under-recognized, especially in regions with high levels of PM2.5, such as China. METHODS: To explore the association between long-term exposure to ambient PM2.5 and CKD prevalence in China, we used data from the China National Survey of CKD, which included a representative sample of 47,204 adults. We estimated annual exposure to PM2.5 before the survey date at each participant's address, using a validated, satellite-based, spatiotemporal model with a 10 km×10 km resolution. Participants with eGFR <60 ml/min per 1.73 m2 or albuminuria were defined as having CKD. We used a logistic regression model to estimate the association and analyzed the influence of potential modifiers. RESULTS: The 2-year mean PM2.5 concentration was 57.4 µg/m3, with a range from 31.3 to 87.5 µg/m3. An increase of 10 µg/m3 in PM2.5 was positively associated with CKD prevalence (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.22 to 1.35) and albuminuria (OR, 1.39; 95% CI, 1.32 to 1.47). Effect modification indicated these associations were significantly stronger in urban areas compared with rural areas, in males compared with females, in participants aged <65 years compared with participants aged ≥65 years, and in participants without comorbid diseases compared with those with comorbidities. CONCLUSIONS: These findings regarding the relationship between long-term exposure to high ambient PM2.5 levels and CKD in the general Chinese population provide important evidence for policy makers and public health practices to reduce the CKD risk posed by this pollutant.