Can the implementation of clinical practice guidelines improve clinical competence of physicians and kidney function of patients with type 2 diabetes mellitus?

Background: There are many clinical practice guidelines (CPGs) in Nephrology; however, there is no evidence that their availability has improved the clinical competence of physicians or the outcome of patients with chronic kidney disease (CKD). This study was aimed to evaluate the effect of implementation of CPGs for early CKD on family physicians (FP) clinical competence and subsequently on kidney function preservation of type 2 diabetes mellitus (DM2) patients at a primary healthcare setting. Methods: A prospective educative intervention (40-h) based on CPGs for Prevention, Diagnosis and Treatment of Early CKD was applied to FP; a questionnaire to evaluate clinical competence was applied at the beginning and end of the educative intervention (0 and 2 months), and 12 months afterwards. DM2 patients with CKD were evaluated during 1-year of follow-up with estimated glomerular filtration rate (eGFR) and albuminuria. Results: After educative intervention, there was a significant increase in FP clinical competence compared to baseline; although it was reduced after 1 year, it remained higher compared to baseline. One-hundred thirteen patients with early nephropathy (58 stage 1, 55 stage 2) and 28 with overt nephropathy (23 stage 3, 5 stage 4) were studied. At final evaluation, both groups maintained eGFR [(mean change) early 0.20 ± 19 pNS; overt 0.51 ± 13 mL/min pNS], whereas albuminuria/creatinuria (early -67 ± 155 p < 0.0001; overt -301 ± 596 mg/g p < 0.0001), systolic blood pressure (early -10 ± 18 p < 0.05; overt -8 ± 20 mmHg p < 0.05), and total cholesterol (early -11 ± 31 p < 0.05; overt -17 ± 38 mg/dL p < 0.05) decreased. Diastolic blood pressure, waist circumference and LDL-cholesterol were also controlled in early nephropathy patients. Conclusions: CPGs for Prevention, Diagnosis and Treatment of CKD, by means of an educative intervention increases FP clinical competence and improves renal function in DM2 patients with CKD.

Multidisciplinary strategies to promote self-care in patients with early nephropathy / Estrategias multidisciplinarias para fomentar autocuidado en pacientes con nefropatía temprana

In Mexico, there is a high prevalence of early nephropathy that usually goes unnoticed and may in part be due to the acquisition of "moderns" negative habits a lifestyle from an early age like physical inactivity, unhealthy diet, smoking and alcohol intake abuse associated with the increasing prevalence of overweight and obesity, diabetes and hypertension, leading causes of chronic kidney disease (CKD) in Mexico. These behaviors are difficult to control by medical intervention alone and may be associated with lack of resources of patients to perform self-care activities and the health care-model predominant in México also may be insufficient to generate healthy behaviors. To improve the care of patients from early stages of CKD, is necessary to implement multidisciplinary strategies to empower the patient and develop their self-efficacy to carry out self-care actions to manage their disease, control risk factors, promotion of healthy habits and modify risk behaviors. Promoting self-care is an area of opportunity with potential benefits to reduce the progression of kidney damage and complications. The aim of this article is to review the main multidisciplinary strategies to promote self-care in patients with early nephropathy in primary health-care.

En México, existe una alta prevalencia de nefropatía temprana que puede pasar desapercibida y deberse a los "modernos" hábitos negativos de un estilo de vida; la inactividad física, la dieta poco saludable, el tabaquismo y el abuso en el consumo de alcohol, asociados al incremento de la prevalencia de sobrepeso y obesidad, diabetes e hipertensión arterial, son las principales causas de enfermedad renal crónica (ERC) en nuestro país. Para mejorar la atención de los pacientes desde los estadios tempranos de la ERC, es necesario implementar estrategias multidisciplinarias para empoderar al paciente y desarrollar su autoeficacia para llevar a cabo acciones de autocuidado para el manejo de su enfermedad, control de factores de riesgo, promoción de hábitos saludables y modificar conductas de riesgo. Fomentar el autocuidado constituye un área de oportunidad con potenciales beneficios para reducir la progresión del daño renal y sus complicaciones. El objetivo de este artículo es revisar las principales estrategias multidisciplinarias para fomentar el autocuidado en pacientes con nefropatía temprana en atención primaria.

Prevalence of pre-diabetes in young Mexican adults in primary health care.

BACKGROUND: Pre-diabetes in young people is frequently unrecognized or not treated on time, with the consequent loss of opportunity for diabetes prevention. In Mexico, there is scarce information about the prevalence of pre-diabetes in young adults. OBJECTIVE: To determine the prevalence and risk factors for pre-diabetes in young Mexican adults in primary health care. METHODS: In a cross-sectional study, 288 subjects, aged 18-30 years, from a primary care unit were included. Pre-diabetes was diagnosed (according to the criteria of the American Diabetes Association) as impaired fasting glucose (8-12 hours fasting plasma glucose level: 100-125 mg/dl) or impaired glucose tolerance (140-199 mg/dl after a 2-hour oral glucose tolerance test). RESULTS: Prevalence of pre-diabetes was 14.6% [95% confidence interval (CI): 10.7-19.2], whereas that of diabetes was 2.4% (95% CI: 1.0-4.9). A high proportion of patients had history of obesity, diabetes, hypertension and consumption of tobacco and alcohol. Pre-diabetic patients were older than normoglycaemics (pre-diabetic patients: 26±4 years versus normoglycaemic subjects: 24±3 years, P = 0.003) and had higher body mass index (BMI; pre-diabetic patients: 29.4±6.8 kg/m(2) versus normoglycaemic subjects: 26.8±5.8 kg/m(2); P = 0.009), particularly in the case of men (pre-diabetic men: 29.3±7.0 kg/m(2) versus normoglycaemic men: 26.4±5.1 kg/m(2); P = 0.03). Although waist circumference showed a trend to be higher among pre-diabetics, no significant differences were found according to gender (among males: pre-diabetics: 99.5±18.8 cm versus normoglycaemics: 93.3±14.4 cm, P = 0.09; among females: pre-diabetics: 91.5±13.8 cm versus normoglycaemics: 85.8±15.9 cm, P = 0.16). Only age and BMI were significantly associated with the presence of pre-diabetes. CONCLUSIONS: Almost 15% of these young adults had pre-diabetes. Many modifiable and non-modifiable risk factors were present in these patients, but only age and a higher BMI were independent variables significantly associated with pre-diabetes. Timely interventions in primary health care are needed to prevent or delay the progression to diabetes.

Multidisciplinary strategies in the management of early chronic kidney disease.

Chronic kidney disease (CKD) is a worldwide epidemic especially in developing countries, with clear deficiencies in identification and treatment. Better care of CKD requires more than only economic resources, utilization of health research in policy-making and health systems changes that produce better outcomes. A multidisciplinary approach may facilitate and improve management of patients from early CKD in the primary health-care setting. This approach is a strategy for improving comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork, eliminating barriers to achieve goals and improving the processes of care. A multidisciplinary intervention may include educational processes guided by health professional, use of self-help groups and the development of a CKD management plan. The complex and fragmented care management of patients with CKD, associated with poor outcome, enhances the importance of implementing a multidisciplinary approach in the management of this disease from the early stages. Multidisciplinary strategies should focus on the needs of patients (to increase their empowerment) and should be adapted to the resources and health systems prevailing in each country; its systematic implementation can help to improve patient care and slow the progression of CKD.