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You are here: Home / Resources / SystmOne Resource Centre / SystmOne Specialties / SystmOne Diabetes Overview / SystmOne Diabetic Kidney Disease

SystmOne Diabetic Kidney Disease

Diabetic kidney disease (DKD) is usually a clinical diagnosis in a patient with long-standing diabetes (>10 years) with albuminuria and/or reduced estimated glomerular filtration rate (eGFR) in the absence of signs or symptoms of other primary causes of kidney damage. 

Prevention of development/progression of DKD is helped by ‘standard’ interventions that also prevent macrovascular disease e.g., 

  • Smoking Cessation 
  • BP Control 
  • Lipid Modification 
  • Hyperglycaemia Management 

Specific interventions are also recommended for patients with diabetes and a persistently raised ACR>=3 (ACEi/A2RB and SGLT2i). 

The following resources will help deliver these interventions:

  • Overall comprehensive strategy for managing Diabetic Albuminuria
  • Improving ACR uptake for patients with Diabetes
  • Improving Albuminuria coding in Diabetes
  • Improving detection of Albuminuria in Diabetes
  • Improving treatment of Albuminuria in Diabetes
Managing/ Preventing Diabetic Albuminuria
Intervention Workload Realistic timeframe Staff Action Search 
Improving ACR testing uptake Run batch searches at regular intervals e.g., fortnightly Ongoing Reception, care – coordinator Contact patient by phone, SMS or email. ACR Uptake for Diabetics – See below
Improve coding of albuminuria Moderate amount of upfront work (often 5-10% of diabetic patients) followed by ongoing small amount of work 1 month GP, nurse practitioner, pharmacist Review record and consider adding appropriate code  Albuminuria Coding for Diabetics – See below
Improving detection of significant albuminuria Moderate amount of upfront work (often 5-10% of diabetic patients) followed by ongoing steady stream of work 3 months All staff Review record and consider repeating ACR Albuminuria Detection for Diabetics – See below
Improving management of diabetic albuminuria (Usually) large amount of upfront work with smaller amount of ongoing work 3 months GP, nurse practitioner, pharmacist (? Suitable trained others e.g. pharmacy technician, practice nurse) Consider prescribing ACEi/A2RB or recording reason why not ACEi/A2RB Treatment for DKD – See below

* NB – patients who have newly coded albuminuria may become eligible for ACEi/A2RB treatment, one of the diabetes QoF indicators.  This process is best avoided towards the end of the QoF year. 

ACR Uptake for Diabetics 

Improving the uptake of ACR testing in patients with diabetes is an important step to improving Diabetes care and prevent of micro and macrovascular morbidity and mortality. 

The two reports highlighted above identify diabetic patients who appear to be overdue ACR testing. The second report provides a more subtle approach and works well if added to an Automated Reporting batch that runs at regular intervals to report to reception or care-coordinators.  

Report NameReturnsActions
? DM 3.201 Nephropathy – ACR not done in last 13m (unless excepted) Patients with diabetes without a record of ACR in the last 13m Consider contacting these patients to invite them to submit urine sample 
? DM 3.202 Nephropathy – Annual review without ACR Patients whose diabetes annual review took place at least a month ago who haven’t yet submitted an ACR Consider contacting these patients to invite them to submit urine sample.  This is a good search to run on a regular (e.g. fortnightly) batch 

Patients can be contacted by phone, SMS or email. 

Suggested text to use in the Communications Annexe 

<forename> <surname> 

Please could you drop in an early morning urine sample to the surgery.  This is due as part of your regular check up. 

Regards 

Organisation Name inserted here 

Albuminuria Coding for Diabetics 

Definitions 

Microalbuminuria – ACR persistently >=3 to 30 (at least 2 out of 3 samples over a few months) 

Albuminuria/Proteinuria – ACR persistently >30 (at least 2 out of 3 samples over a few months) 

Coding Issue 

QoF only ‘recognises’ patients with diabetes as having microalbuminuria/albuminuria if they have one of the Snomed codes from the MAL (micoralbuminuria) or PRT (proteinuria) code clusters.  The most appropriate codes from these clusters are shown below.  QoF does not ‘count’ either ACR numeric results >=3 or CKD codes which confirm microalbuminuria e.g. CKD G3a A2 (although QoF does recommend proteinuria CKD codes such as CKD G3b A3) 

These are the recommended codes to use for diabetic patients with persistently abnormal ACR results. 

Diabetes Type ACR >3 ACR >30 
Type 1 Type 1 diabetes mellitus with persistent microalbuminuria Type II diabetes mellitus with persistent microalbuminuria 
Type 2 Type II diabetes mellitus with persistent microalbuminuria Type II diabetes mellitus with persistent proteinuria 
Other diabetes Diabetes mellitus with persistent microalbuminuria Diabetes mellitus with persistent proteinuria 

The earliest code from these clusters will be shown in the renal panel of the diabetes template. 

o 
Renal Function Coding 
ACEi/A2Ra 
8 Mar 2021 
8 Mar 2021 
1 Mar 2021 
01 Mar 2021 
10 Jan 2020 
serum creatinine level [XE2q5) (SNOMEO: 1 umoI/L 
GFR calculated abbreviated MORO rxaK8y) (SNO 
> go mlJmin/1 
urine albumin/creatinine ratio [XE2n3) (SNOMEDL 3 mg/mmol 
Urine albumin/creatinine ratio [XE2n3) (SNOMEO: 1 0234g1 0000001 04) 
Type Il diabetes mellitus with persistent microalbuminuria (XalzR) (SN 
Done in last 12m 
A Done in last 12m 
OOF NOT Achieved 
consider ACEi/A2RB

The following reports will help to identify and manage these patients

These reports can be found in the folder CDRC Quality > Diabetes IGR 

7 0M 3201 Nephropathy - ACR not done in last 13m (unless excepted) 
7 0M 3202 Nephropathy - Annual review without ACR 
0M 321 Ne hro ath -Diabetic with ersistent albuminuria Out no aoF albuminuria code 
7 0M 3 211 Nephropathy - Diabetic with repeated albuminuria but no OOF albuminuria code on repeat ACEi/A2R8 
? DM 3212 Nephropathy - Diabetic With CKD 4.2/3 but no OOF albuminuria code 
7 0M 322 Nephropathy - Consider repeating ACR test 
7 0M 3 23 Nephropathy - Consider ACEi/A2R8 for diabetic kidney disease
Report NameReturnsActions
? DM 3.21 Nephropathy – Diabetic with persistent albuminuria but no QoF albuminuria code Patients whose last 2 ACR results are >=3 but who do not have a code in the MAL or PRT clusters Review record and consider adding relevant code from list above 
? DM 3.211 Nephropathy – Diabetic with repeated albuminuria but no QoF albuminuria code on repeat ACEi/A2RB Patients who are already on an ACEi/A2RB who appear to have had repeated ACR results >=3 Review record and consider adding relevant code from list above.  NB this report will improve QoF performance. 
? DM 3.212 Nephropathy – Diabetic with CKD A2 but no QoF albuminuria code Patients whose latest CKD code indicates they have significant albuminuria but who don’t have a code from the MAL cluster Review record and consider adding relevant code from list above 
Albuminuria Detection for Diabetics 

Definitions 

Microalbuminuria – ACR persistently >=3 to 30 (at least 2 out of 3 samples over a few months).

Albuminuria/Proteinuria – ACR persistently >30 (at least 2 out of 3 samples over a few months).

Patients with an isolated raised ACR should have a repeat ACR measured to confirm or refute persistent abnormality.

This report will identify patients with diabetes who might have microalbuminuria/albuminuria who can be offered a repeat test.

This report can be found in the folder CDRC Quality > Diabetes IGR

0M 3201 Nephropathy 
7 0M 3202 Nephropathy 
g processes missing (unless excepted) 
- ACR not done in last 13m (unless excepted) 
- Annual review without ACR 
7 0M 321 Nephropathy - Diabetic with persistent albuminuria but no OOF albuminuria code 
7 0M 3 211 Nephropathy - Diabetic with repeated albuminuria but no OOF albuminuna code on repeat ACEi/A2R8 
7 0M 3212 Nephropathy - Diabetic with CKD 4.2/3 Out no OOF albuminuria code 
0M 322Ne hro ath -Consider re eatin ACR test 
? 0M 323 Nephropathy - Consider ACEi/A2R8 for diabetic kidney disease
Report NameReturnsActions
? DM 3.22 Nephropathy – Consider repeating ACR test Patients whose last ACR result (at least two months ago) is >=3 who don’t have a code in the MAL/PRT clusters Review record and consider requesting repeat ACR testing to confirm/refute albuminuria 

Patients can be contacted by phone, SMS or email. 

Suggested text to use in the Communications Annexe 

<forename> <surname> 

Please could you drop in an early morning urine sample to the surgery.  This is due as part of your regular check up. 

Regards 

Organisation Name inserted here 

ACEi/A2RB Treatment for DKD 

Renin-angiotensin system blockade offers significant benefits to patients with diabetes and persistent ACR>=3.  Benefits include reductions in poor renal and cardiovascular outcomes. 

One of the diabetes QoF indicators is based on RAS blockade for patients with diabetes and albuminuria. 

This report will identify patients with diabetes who have coded albuminuria and who are not taking an ACEi/A2RB or don’t have a good reason why not.  See Albuminuria Coding for Diabetics for coding issues (above). 

This report can be found in the folder CDRC Quality > Diabetes IGR

7 0M 3201 Nephropathy - ACR not done in last 13m (unless excepted) 
7 0M 3 202 Nephropathy - Annual review without ACR 
7 0M 321 Nephropathy - Diabetic with persistent albuminuria but no OOF albuminuria code 
7 0M 3 211 Nephropathy - Diabetic with repeated albuminuria Out no OOF albuminuria code on repeat ACEi/A2R8 
7 0M 3 212 Nephropathy - Diabetic with CKD 4.2/3 Out no OOF albuminuria code 
7 0M 322 Nephropathy - Consider repeating ACR test 
0M 323 Ne hro ath -Consider ACEi/A2R8for diabetic kidne disease
Report NameReturnsActions
? DM 3.22 Nephropathy – Consider repeating ACR test Patients whose last ACR result (at least two months ago) is >=3 who don’t have a code in the MAL/PRT clusters Review record and consider requesting repeat ACR testing to confirm/refute albuminuria 

‘Good reason why not’ is defined as: 

Adverse reaction to ACEi (ever)  OR ACEi declined/not indicated/not tolerated/contraindicated (last 12m) 

AND 

Adverse reaction to A2RB (ever)  OR A2RB declined/not indicated/not tolerated/contraindicated (last 12m) 

A warning about considering the need for ACEiA2RB will be displayed on the diabetes template, along with the current QoF status. A link to the ACEi/A2RB template is available. 

Machine generated alternative text:
o 
Renal Function Coding 
ACEi/A2Ra 
8 Mar 2021 
8 Mar 2021 
1 Mar 2021 
01 Mar 2021 
10 Jan 2020 
serum creatinine level [XE2q5) (SNOMEO: 1 umoI/L 
GFR calculated abbreviated MORO rxaK8y) (SNO 
> go mLJmin/1 
urine albumin/creatinine ratio [XE2n3) (SNOMEDL 3 mg/mmol 
Urine albumin/creatinine ratio [XE2n3) (SNOMEO: 1 0234g1 0000001 04) 
Type Il diabetes mellitus with persistent microalbuminuria (XalzR) (SN 
Done in last 12m 
A Done in last 12m 
OOF NOT Achieved 
consider ACEi/A2RB
Machine generated alternative text:
ACEijA2RB Exceptions Indications and Dosing Equivalent Doses 
ACEi/A2RB 
CKS - ACEi 
CKS - 
More detailed information about indications and dosages 
All ACEi/A2Ra Issues 
ACEi/A2R8 Exceptions 
C) Angiotensin system drug target dose achieved 
C) Angiotensin system drug target dose not achieved 
More detailed information about targets 
ACEi/A2Ra Checklist 
ACEi/A2RBs not on repeat 
ACEi/A2RB Possible Indication - Hypertension 
ACEi/A2RB Usually Recommended - Diabetes and micro/albuminuria 
ACEi/A2RB Usually Recommended - Diabetes and CHD 
Mar 2011 
Notes 
NAngiotensin-conven-enz inhib caus advers efftherap use (IJ60C4) (SNOMED: 2g3500 
cough with enalapril 
DCS ACEi/A2RB Target view has no data for patient 
Serum sodium level 
Serum potassium level 
Serum creatinine level 
GFR calculated abbreviated MORO 
DCS ACEi/A2RB Checklist view has no data for patient 
138 mmol/L 
44 mmol/L 
47 umol/L 
> go mumin/l 
73m*2 
08 Mar 2021 
08 Mar 2021 
08 Mar 2021 
08 Mar 2021

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