Management of adults with diabetes on the haemodialysis unit: summary of guidance from the Joint British Diabetes Societies and the Renal Association

Abstract

Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, with complex comorbidities, and are at high risk of adverse cardiovascular outcomes, the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and end-stage renal failure require improved delivery of care to overcome organizational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of people with diabetes on maintenance haemodialysis. The guidelines are based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and people with diabetes to promote empowerment and self-management.

Eye and foot checks in patients with diabetes on haemodialysis: Are they done, and who does them?

“…This is of some concern, particularly as patients with diabetes on haemodialysis are at high risk of foot problems. Recent guidelines recommend that patients have their feet screened every 3 mo with a locally agreed tool, and by staff on the dialysis unit[ 4 ].…”

“…We have previously noted poor attendance to other clinics and appointments in patients on haemodialysis. East London is an area of high social deprivation, and many patients are elderly, with multiple co-morbidities, whose first language is often not English, and these factors may affect their ability to access healthcare[ 4 ]. Patients with diabetes on haemodialysis are at particular risk of foot and eye problems[ 5 ].…”

“…Recent United Kingdom guidelines highlight the need for annual foot and eye screening for patients with diabetes on haemodialysis[ 4 ]. The aim of this study was to determine if patients with diabetes on our haemodialysis unit could recall having retinal screening and foot surveillance in the past year, and to find out who had performed this.…”

Safe care for people with diabetes in hospital

“…In addition, rapid fluid changes and the presence of several comorbidities makes the care of people with diabetes on the dialysis unit very challenging. 46 In particular, they often have peripheral vascular disease and are at great risk of developing diabetes-related foot disease. 47 Individuals with chronic kidney disease or on dialysis also have a higher risk of hypoglycaemia and avoidance of hypoglycaemia should remain a priority particularly when they are acutely unwell.…”

Clinical guidelines in diabetes

“…In this issue of Diabetic Medicine , we publish the first in a series of clinical guidelines for inpatients with diabetes produced by the Joint British Diabetes Societies (JBDS) for Inpatient Care group and to which more than 150 UK diabetes clinicians contributed . The areas covered include self‐management of diabetes in hospital , diabetes in people with mental illness , glucose control in the latter part of pregnancy , steroid‐induced hyperglycaemia and diabetes on the haemodialysis unit .…”