Case Study: Monitoring bloods in Type 1 Diabetic

Accelerated renal function deterioration in a Type 1 diabetic.

Purpose of case study: Patient (male aged 46) was found to have diminishing renal function over a course of 6 years. This led to a complete renal failure. There were no intrinsic renal disease or post-renal reasons for deterioration in kidney function. However, there had been a combination of pre-renal factors and MH issues that possibly led to decline in renal function; explained below:

• Non-compliance with Diabetic medication (known to have proliferative diabetic retinopathy, microvascular disease, Diabetic nephropathy)
• Persistently raised BP, again due to non-compliance. We have several documentations of patient not taking the medication. Safeguarding concerns raised about this non-compliant Type-1 diabetic.
• Many hospital admissions with nausea/ vomiting. Some were diagnosed as DKA, one as AKI.
• Increments made in ACE inh medication without F-up renal function check
• Ramipril was not only continued but the dose was increased from 7.5mg to 10mg (21^st Mar-2018 despite patient’s eGFR dropping below 35 (27^th Sep 2017). Maximum recommended dose of Ramipril in patients with eGFR 30-60ml/min is 5mg OD.

Known diagnosis at the start of case: Type 1 diabetic, diagnosed at the age of 19 (1994), Raised BP in Diabetes since 2004

Timeline of significant events:

Date	eGFR (ml/min)	S. Creatinine (µmol/L)
Jan-2014	>90ml	84
May-2015	70	107
2016: Two hosp admission; one due to possible DKA, second one due to inability to manage his insulin at home due to visual impairment. By now patient had bilateral vitreous haemorrhages and has severe visual impairment. Seen by MH as patient is suicidal and has lost almost all ADL.
1st May 2017 hospitalised with Vomiting. Treated with IV fluids. ↑ in dose of Ramipril from 5mg OD to 7.5mg OD No F-up of renal tests performed at Diabetes clinic or GP surgery
11th Sep 2017 Diabetes clinic initiates Amlodipine 5mg OD
27th Sep 2017	34	189
21st Mar 2018 the dose of Ramipril increased from 7.5mg OD to 10mg OD
22nd Aug 2018 admitted to hospital with Vomiting / nausea. At hospital first time renal team input re dropping renal function
22nd Aug-2018	22	279
3rd Sep 2018 Ramipril dose reduced from 10mg OD to 2.5mg OD Also dose of amlodipine increased to 10mg OD
2nd Nov 2018	18	335
27th Nov 2018 Diabetes clinic suggests stopping Ramipril following a repeat B.test
28th Nov 2018 A renal ultrasound arranged
5th Dec 2018 Ramipril Stopped , Doxazosin initiated
24th Jan 2019: Results of renal USS normal excluding intrinsic renal disease
13th Feb 2019 referred for Pancreatic Transplant
6th Mar 2019	12	465
1st Apr 2019 : Renal clinic initiates Moxonidine 200mg OD
8th May 2019: Dose of Moxonidine increased to 400mg OD
8th June 2019: Hospitalised with AKI (pre-renal cause; dehydration)
21st July 2019	8	641
16th Sep 2019: Now suitable for SKP (simultaneous Kidney-pancreatic transplant)
18th Dec 2019	5	898
27th May 2020 has a respect form in place. Patient is not for DNACPR
22nd July 2021 Received SKP transplant
22nd July 2021 (pre-transplant)		2018
10th Aug 2021 (post transplant)		224
14th Sep 2021 re-admitted due to chronic peri-pancreatic fluid collection. Amlodipine + Moxonidine STOPPED at hosp as BP now acceptable
10th Nov 2021		183 Awaiting kidney USS

What might have led to renal failure:

• Patient factors: Poor insight into his long-term disease. Inability to appreciate rapid progression of microvascular disease and suboptimal control of his diabetes. Visual impairment made it further difficult to test BS, administer insulin safely.
• Health Care Provider factors: His decline in renal function did not get spotted as a concern until hie eGFR dropped to 34ml/min and S.creatinine raised to 189µmol/L. Additionally, he had been prescribed ACE inhibitor at a dose that caused further renal function deterioration. This episode was 6 months long (Mar-Sep 2018). During this period his renal function declined by more than 35% and eGFR reduced from 34ml/min to 22ml/min. Another 3 months later a decision was made to STOP Ramipril. By now the eGFR is as low as 12ml/min (Mar-2019). He suffered from AKI in June 2019 and eGFR dropped to only 8ml/min.

What opportunities have been missed by Health Care providers:

• No documentation of patient being referred to Structured Diabetes programme.
• Patient was known to his prescriber as a sufferer of Depression since 2007. Patient was first time seen by MH team in 2016 following being suicidal after having lost vision in both eye sand being unable to administer his insulin. This could have been picked up earlier, following vision loss in one eye only with partial non-compliance to Diabetes medication.
• Recommendation of medication from Diabetes clinic e.g. Ramipril dose increment had not been challenged by the primary care prescriber.
• Patient has been registered blind since 2015. On 22^nd June 2015, patient himself requests to have referral made to Diabetes clinic as he can no longer manage it. Patient’s current record still has no appropriate notice displaying to HCP that the patient is registered Blind.
• No documentation / coded entry for Diabetes management plan or an individualised care plan to date.
• No documentation of the events of DKA, AKI after hospitalisation .

How will I change my practise?

• A holistic approach will be used for patients with chronic disease diagnosis.
• When correspondence received from secondary care it will be checked against most recent investigations. This will help identify a sudden change or a trend of change in patient’s parameters.
• Medication recommendations from outpatient clinics, discharge notification will be reviewed more carefully. I will be prepared to question an addition, discontinuation or alteration to current regime which may not be suitable for the individual in question.
• Ensuring that all relevant medical / social information is read coded wherever possible. E.g. in this case a pop-up notice for the clinician/ reception desk that patient is blind/ partially sighted can help adapt better ways of communication. This patient is not suitable to be contacted via AccuRx etc for urgent messages and should receive a voice call instead.

  Example of what is achieved:

  We have adopted a more careful approach on summarising correspondence from other HCP. Below are few examples.

  • We received advice from Rheumatology for a patient with seronegative RA, to increase the dose of Methotrexate from 20mg weekly to 25mg Weekly via oral route. Given that maximum recommended dose of Methotrexate is 20mg Weekly, we wrote back to Rheumatology dept. requesting to review their advice. Please find below a snapshot of OPD letter summarising:
  • We received advice from Pain management clinic advising to prescribe a reducing dose regime of Gabapentin. We have found many instances where a reducing regime is started but due to inadequate follow-up patients have failed to come off the relevant medication (mostly Schedule 2, 3 drugs). Therefore we prepared an individualised dose reduction regime for the patient and this was sent to patient via both electronic copy and a letter in post. Patient also received a telephone call explaining reducing dose regime and agreed for 4 weekly reviews for additional support.

  Please find below the image of both documentation of the letter from Pain management and the individualised reducing dose plan.

  We aim to review patient every 4 weeks which enables both clinician and patient to exchange any concerns, intercurrent illness, withdrawal effects etc

  Written by Aneela Tehseen