Multidisciplinary Team Care Delays the Initiation of Renal Replacement Therapy in Diabetes: A Five-year Prospective, Single-center Study

Abstract

Objective Although recent reports have highlighted the benefits of multidisciplinary team care (MTC) for chronic kidney disease (CKD) in slowing the progress of renal insufficiency, its long-term effects have not been evaluated for patients with diabetes mellitus (DM). We compared the renal survival rate between MTC and conservative care (CC). Methods In this five-year, single-center, prospective, observational study, we examined 24 patients (mean age 65.5±12.1 years old, men/women 18/6) with DM-induced CKD stage ≥3 in an MTC clinic. The control group included 24 random patients with DM (mean age 61.0±12.8 years old, men/women 22/2) who received CC. MTC was provided by a nephrologist and medical staff, and CC was provided by a nephrologist. Results In total, 10 MTC and 20 CC patients experienced renal events [creatinine doubling, initiation of renal replacement therapy (RRT), or death due to end-stage CKD]. During the five-year observation period, there were significantly fewer renal events in the MTC group than in the CC group according to the cumulative incidence method (p=0.006). Compared to CC, MTC significantly reduced the need for urgent initiation of hemodialysis (relative risk reduction 0.79, 95% confidence interval [CI] 0.107-0.964). On a multivariate analysis, MTC (hazard ratio [HR], 0.434, 95% CI 0.200-0.939) and the slope of the estimated glomerular filtration rate during the first year (HR, 0.429 per 1 mL/min/m²/year, 95% CI 0.279-0.661) were negatively associated with renal events. Conclusion MTC for DM-induced CKD is an effective strategy for delaying RRT. Long-term MTC can demonstrate reno-protective effects.

Keywords: chronic kidney disease; diabetic nephropathy; end-stage renal disease; multidisciplinary team care; renal replacement therapy; urgent initiation of renal replacement therapy.

Figure 1.

Flowchart of the patient selection process and main outcomes. CKD: chronic kidney disease, DM: diabetes mellitus, eGFR: estimated glomerular filtration rate, ESRD: end-stage renal disease

Figure 2.

Education program for patients with CKD enrolled in the MTC clinic. This original MTC program consisted of a series of six sessions of medical education for patients to enhance their comprehension and establish their overall knowledge of diabetes mellitus pathology every two months for one year. BP: blood pressure, BW: body weight, CKD: chronic kidney disease, MTC: multidisciplinary team care

Figure 3.

a: A comparison of main parameters in both MTC and CC groups before and after the one-year observation period. We compared the mean values of the main parameters related to the evaluation of MTC or CC for DM-induced CKD before and after the one-year observation period. The mean eGFR slope increased significantly in the MTC group but not in the CC group. Among other markers, urine protein, HbA1c, systolic blood pressure, and diastolic blood pressure showed no significant change in either group, indicating that the renal function was not associated with these main parameters, except for the eGFR slope, in the MTC or CC group. b: A comparison of the estimated salt and protein intake using 24-hour urine samples in the MTC group before and after the one-year MTC clinic. We compared the mean values of the estimated salt and protein intake in the MTC group before and after the one-year MTC clinic. Both parameters were evaluated by the Mann-Whitney U-test and showed no significant change during this period. Differences were considered significant when p<0.05. BP: blood pressure, CC: conservative care, DM: diabetes mellitus, eGFR: estimated glomerular filtration rate, HbA1c: hemoglobin A1C, MTC: multidisciplinary team care, ns: not significant, UP: urine protein

Figure 4.

Results of a survival analysis using the cumulative incident function for the occurrence of renal events. We used the cumulative incident function for renal events of the MTC and CC groups over five years. We represented the cumulative occurrence rate of the renal events, including creatinine doubling, initiation of RRT, and renal death. We performed a Gray test, and differences were considered significant when p<0.05. CC: conservative care, MTC: multidisciplinary team care, RRT: renal replacement therapy