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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION AND OBJECTIVES </span></p><p class="elsevierStylePara">Chronic kidney disease &#40;CKD&#41; is one of the most common and damaging complications of type 2 diabetes mellitus &#40;T2DM&#41;&#46; Often patients with T2DM have CKD and this process&#44; in addition to notably increasing cardiovascular morbidity and mortality&#44; is the leading cause of kidney replacement treatment in most countries&#46;<span class="elsevierStyleSup">1&#44;2 </span>We currently have therapeutic options to improve its evolution&#44; especially if detected in the early stages&#46;<span class="elsevierStyleSup">3-5 </span>These data reinforce the need for early detection and proper treatment of this disease&#44; which makes the close collaboration between nephrology and primary care essential&#46;<span class="elsevierStyleSup">6 </span></p><p class="elsevierStylePara">Current epidemiological data give us a better idea of the scale of the CKD problem&#46; The EPIRCE study detects a prevalence of CKD in the general population of 9&#46;06&#37; in Spain&#44;<span class="elsevierStyleSup">7 </span>and two studies addressing the impact of this disease in primary care indicate a prevalence of 21&#46;3&#37; in the EROCAP<span class="elsevierStyleSup">8 </span>study and 16&#46;4&#37; in the Alca&#241;iz health sector<span class="elsevierStyleSup">9 </span>in patients attended to in health centres&#46; However&#44; no epidemiology studies have been conducted to estimate the prevalence of CKD in patients with T2DM monitored in primary care&#46;</p><p class="elsevierStylePara">Our aim was to estimate the impact and importance of CKD in patients with T2DM checked at health centres&#46; We have developed this study for that purpose with the following two objectives&#58;</p><p class="elsevierStylePara">1&#46; Estimate the prevalence of CKD in patients with T2DM monitored in primary care in health centres of the Alca&#241;iz health sector&#46;</p><p class="elsevierStylePara">2&#46; Analyse the impact of this process on the activity and workload of our outpatient nephrology&#44; determining the number of patients who met criteria for referral proposed in the Consensus Document by the Spanish Society of Nephrology and the Spanish Society of Family and Community Medicine &#40;S&#46;E&#46;N&#46;-SEMFyC&#41;&#46;<span class="elsevierStyleSup">10 </span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIALS AND METHODS </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Study design </span></p><p class="elsevierStylePara">Transversal descriptive epidemiology study&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Studied population </span></p><p class="elsevierStylePara">Patients of both genders&#44; older than 18 years&#44; diagnosed with T2DM&#44; and in whom a biochemical determination had been performed for any reason in any of the 16 health centres of the Alca&#241;iz health sector &#40;serving a total of 84&#44;340 inhabitants&#41; between Janurary 1<span class="elsevierStyleSup">st </span>and December 31<span class="elsevierStyleSup">st </span>2008 were included&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Selection of patients diagnosed with type 2 diabetes mellitus treated in primary care </span></p><p class="elsevierStylePara">In the process of improving the quality of CKD treatment previously performed in our health sector with collaboration between nephrology&#44; endrocrinology&#44; biochemistry department and primary care&#44; analytical request profiles were established&#46; One of these is the &#8220;DM profile&#8221; which specifically determines glycated haemoglobin&#44; glomerular filtration rate and the albumin-to-creatinine ratio in single urine samples&#46; We have considered as diabetic those patients for whom the attending physician first made the request with this profile&#44; independently of the values of glucemia or glycosylated haemoglobin that could be determined in a given analysis&#46; Meanwhile&#44; we believe the absence of analytical results from endocrinology between January 1&#44; 2006 and December 31&#44; 2008 &#40;dates of the computerisation of laboratory services&#41; means that follow-up of patients was done by primary care&#46; We intended to limit the study to DM2 and to relate it in percentages to this group of the adult population&#46; For this reason we limited the study to those older than 18&#44; after consulting with endocrinology that all patients with type 1 DM &#40;DM1&#41; are reviewed in their offices and&#44; therefore&#44; are excluded from the study&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Variables collected </span></p><p class="elsevierStylePara">Using a computerised process in the Department of Biochemistry at Alca&#241;iz Hospital&#44; demographic data were collected &#40;gender and age&#41; and analytical assessments &#40;serum creatinine &#91;sCr&#93;&#44; glycosylated hemoglobin&#44; potassium&#44; haemoglobin and the albumin&#47;creatinine ratio in urine&#41; were carried out&#46; If there were several analytical determinations in the same patient&#44; the one that had lower creatinine was collected&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Biochemical methods </span></p><p class="elsevierStylePara">CRP was determined using a modified kinetic Jaff&#233; method with an autoanalyser Architec C-8000 &#40;Abbot Scientific&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Definitions </span></p><p class="elsevierStylePara">The estimated Glomerular Filtration Rate &#40;eGFR&#41; was calculated using the MDRD study equation &#40;Modification of Diet in Kidney Disease&#41;&#58; Estimated GFR &#61; 186 x &#40;creatinine&#41; -1&#46;154 x &#40;age&#41; -0&#46;203 x &#40;0&#46;742 if female&#41; x &#40;1&#46;210 if black&#41;&#46;<span class="elsevierStyleSup">11&#44;12 </span>Criteria used were K&#47;DOQI in the definition and staging of CKD&#46; Microalbuminuria was defined as the presence of a simple urinary albumin&#47;creatinine ratio between 30 and 300 mg&#47;g&#44; and macroalbuminuria as a ratio greater than 300 mg&#47;g&#46;</p><p class="elsevierStylePara">As criteria for referral to nephrology&#44; consultations were adopted as proposed in the SEN-semFYC Document&#46; According to this consensus&#44; patients should be referred to nephrology with DM2 and CKD&#44; considering eGF values &#40;under 70 years&#58; eGFR &#60;45 mL&#47;min&#47;1&#44; 73 m2&#44; over 70 years&#58; EFG &#60;30 mL&#47;min&#47;1&#44; 73 m2&#41; and values of urinary albumin excretion &#40;albumin&#47;creatinine ratio in urine&#62; 300 mg&#47;g&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical analysis </span></p><p class="elsevierStylePara">The description of quantitative traits was performed using mean and standard deviation&#44; and the qualitative characteristics by frequency distribution&#46; We calculated the 95&#37; confidence interval &#40;CI&#41; of the estimated rate of patients with DM2 and CKD&#46; The statistical significance of differences between rates was assessed using the chi-squared test&#46; The statistical significance of differences between averages of independent groups was assessed using the Student&#8217;s t test&#46; P-values &#60; 0&#46;05 were considered significant&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara">During the 12 months reviewed&#44; 18&#44;898 CRP determinations were conducted in 17&#44;963 patients in the health centres&#46; 1096 determinations were excluded &#40;5&#46;8&#37;&#41; because they were repeated in the same individual &#40;in this case we consider only those with the lowest CRP value&#41; and 888 &#40;4&#46;7&#37;&#41; for not including age in the analysis request&#44; making us unable to estimate the GFR&#46; Lastly&#44; data on the 16&#44;814 patients were included&#46;</p><p class="elsevierStylePara">Out of the total number of patients&#44; 3&#46;466 &#40;20&#46;6&#37;&#41; presented with DM2&#46; Age&#44; percentage of men and potassium values were higher in subjects with T2DM&#44; while haemoglobin was similar in patients with and without DM2 &#40;Table 1&#41;&#46;</p><p class="elsevierStylePara">The incidence of CKD and micro-macroalbuminuria was 34&#46;6&#37; &#40;95&#37;&#44; 33-36&#46;2&#41; and 16&#46;1&#37; &#40;IC 95&#37;&#44; 14-18&#46;2&#37;&#41;&#44; respectively&#44; in subjects with T2DM&#44; which was significantly higher than the reported incidence in unaffected DM subjects &#40;Table 2&#41;&#46; They had an eGFR &#60;60 mL&#47;min&#47;m<span class="elsevierStyleSup">2 </span>25&#46;2&#37; of DM2 patients&#44; registering the presence of micro-macroalbuminuria in 31&#46;7&#37; of cases&#46;</p><p class="elsevierStylePara">Glycated hemoglobin did not correlate with eGFR &#40;r &#61; 0&#46;008&#44; p &#61; 0&#46;65&#41; but it did with age &#40;r &#61; -0&#46;495&#44; p&#60;0&#46;001&#41;&#46; In cases with micro-macroalbuminuria&#44; mean age was significantly higher &#40;72&#46;5 &#177; 12 vs 67&#46;5 &#177; 12 years&#44; p&#60;0&#46;0001&#41; and so was glycated haemoglobin &#40;7&#46;36 &#177; 1 5 versus 6&#46;8 &#177; 1&#46;2&#37;&#44; p &#61; 0&#46;001&#41;&#46;</p><p class="elsevierStylePara">One hundred four patients with DM2 &#40;3&#37;&#41; and 132 of those without DM2 &#40;1&#37;&#41; met the criteria for referral to nephrology specialists &#40;p&#60;0&#46;0001&#41;&#46; Of the patients with T2DM who met criteria for referral&#44; 78&#46;9&#37; had micro-macroalbuminuria&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">Patients diagnosed with T2DM managed in primary care represent a significant percentage of routine work of health centres&#46; The frequency of CKD in this group is very high at 34&#46;6&#37;&#44; which means that one out of three patients will have even greater cardiovascular and renal risks&#46; Furthermore&#44; the high prevalence of micro-macroalbuminuria at 16&#46;1&#37;&#46; adds another factor that we know effects the morbidity and the development of terminal CKD&#46;</p><p class="elsevierStylePara">In terms of the aetiology of CKD in DM2&#44; as well as diabetic nephropathy&#44; hypertensive nephroangiosclerosis and renal vascular disease are common causes&#46; Therefore&#44; up to 50&#37; of patients with DM2 and a significant decrease in eGFR did not have micro-macroalbuminuria&#44; in contrast to CKD from classical diabetic neuropathy&#46;<span class="elsevierStyleSup">13 </span>Although the risk of terminal CKD does not appear to differ significantly if renal involvement is related to diabetic nephropathy or other diagnostic groups&#44;<span class="elsevierStyleSup">14 </span>it seems appropriate to perform a screening for albuminuria as well as an assessment of renal function in the identification of CKD in DM2&#46; Indirectly&#44; the fact that the eGFR is not correlated with glycated haemoglobin and it is with age&#44; while the presence of micro-macroalbuminuria is related to older age and higher levels of glycated hemoglobin&#44; suggests that the decline of eGFR may depend on other diseases&#44; while the micro-macroalbuminuria would relate more with diabetic nephropathy&#46;</p><p class="elsevierStylePara">It is important to consider that people with DM2 and CKD have a high cardiovascular and renal risk&#44; and that actions to reduce this risk are priorities&#46;<span class="elsevierStyleSup">15&#44;16 </span>Its evolution significantly improves if the disease is detected at an early stage and an appropriate treatment program is implemented&#46; For this reason&#44; in the document agreed upon by the S&#46;E&#46;N&#46;-SEMFyC&#44; special attention is paid to these patients&#44; setting some reasonable objectives for detection&#44; treatment and control&#46; Cardiovascular risk as well as the evolution to terminal CKD in patients with T2DM can be reduced by adequate glycemic control &#40;target glycosylated hemoglobin less than 7&#37;&#41;&#44; a reduction of blood pressure values &#40;to 130&#47;80 mmHg&#41;&#44; good control of dyslipidemia &#40;target LDL cholesterol below 100 mg&#47;dL&#41; and the introduction of drugs capable of blocking the renin-angiotensin system&#44; and also avoiding nephrotoxic drugs and monitoring even relatively trivial processes that may lead to renal function impairment&#46;</p><p class="elsevierStylePara">These actions constitute a remarkable effort in a large population&#44; which in our health sector would cover at least 1199 patients&#46; If we apply the referral criteria in the SEN-semFYC document&#44; 3&#37; of them should be referred to nephrology specialists&#44; three times higher than non-diabetics subjects&#46; Previous estimates and the growth experienced in our consultations after the release of a protocol for treatment of common CKD in primary care &#40;about 37&#37;&#41;<span class="elsevierStyleSup">9&#44;17 </span>highlight the limited resources available for attention to this process&#44; enhancing the need for collaboration between nephrology and primary care to share in the care of patients with CKD&#46;</p><p class="elsevierStylePara">There are&#44; in our study and in general in epidemiological studies on the CKD&#44;<span class="elsevierStyleSup">7&#44;8&#44;18 </span>some limitations&#46; These studies are carried out with a single time point&#44; so transient alteration of renal function cannot be distinguished from established CKD&#46; Also&#44; we do not have a gold standard for estimating GFR&#44; although the MDRD formula does seem appropriate in population studies&#46;<span class="elsevierStyleSup">1&#44;2 </span>As an advantage the large sample size should be noted&#44; which allowed higher accuracy in estimating the prevalence of CKD in patients with DM2&#46;</p><p class="elsevierStylePara">We conclude that the frequent presence of CKD &#40;34&#46;6&#37;&#41; and micro-macroalbuminuria &#40;16&#46;1&#37;&#41; in patients with T2DM followed in primary care is an important factor in cardiovascular and renal risk that must be detected early and treated properly&#46; A significant percentage of patients met the criteria agreed by SEN-semFYC for referral of diabetic patients &#40;3&#37;&#41;&#46; Collaboration with primary care is essential in the early detection&#44; control and monitoring of these high-risk patients&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10260&#95;108&#95;9195&#95;en&#95;10260&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10260_108_9195_en_10260_t1.jpg" alt="Demographic and analytic data of patients with type 2 diabetes mellitus and non-diabetics "></img></a></p><p class="elsevierStylePara">Table 1&#46; Demographic and analytic data of patients with type 2 diabetes mellitus and non-diabetics </p><p class="elsevierStylePara"><a href="grande&#47;10260&#95;108&#95;9196&#95;en&#95;10260&#95;t2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10260_108_9196_en_10260_t2.jpg" alt="Stages of chronic kidney disease and presence of micro&#47;macro albuminuria in patients with type 2 diabetes mellitus and non-diabetic patients "></img></a></p><p class="elsevierStylePara">Table 2&#46; Stages of chronic kidney disease and presence of micro&#47;macro albuminuria in patients with type 2 diabetes mellitus and non-diabetic patients </p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n y objetivos&#58;</span> La frecuencia e importante repercusi&#243;n cl&#237;nica de la enfermedad renal cr&#243;nica &#40;ERC&#41; en los pacientes con diabetes mellitus tipo 2 &#40;DM2&#41;&#44; junto con la posibilidad de mejorar su evoluci&#243;n mediante una intervenci&#243;n precoz&#44; refuerza la necesidad de una estrecha colaboraci&#243;n en su detecci&#243;n y tratamiento entre nefrolog&#237;a y atenci&#243;n primaria&#46; <span class="elsevierStyleBold">Objetivos&#58; </span>Los objetivos del estudio son estimar la prevalencia de ERC en los pacientes con DM2 controlados en atenci&#243;n primaria en nuestro sector sanitario y determinar el volumen de pacientes que ser&#237;an remitidos&#160;a las consultas de nefrolog&#237;a&#46; <span class="elsevierStyleBold">Material y m&#233;todos&#58; </span>Se incluyeron pacientes mayores de 18 a&#241;os de edad&#44; en los que se hab&#237;a realizado anal&#237;tica por cualquier motivo en los 16 centros de salud del sector sanitario de Alca&#241;iz &#40;84&#46;340 habitantes&#41; a lo largo de 2008&#46; Se recogieron datos demogr&#225;ficos &#40;edad y sexo&#41;&#44; creatinina plasm&#225;tica&#44; cociente alb&#250;mina&#47;creatinina en orina simple&#44; hemoglobina glicosilada&#44; potasio y hemoglobina&#46; Se calcul&#243; el filtrado glomerular estimado &#40;eFG&#41; por la f&#243;rmula MDRD&#46; Se revisaron los criterios de remisi&#243;n a nefrolog&#237;a de acuerdo con el Documento de Consenso sobre ERC de la Sociedad Espa&#241;ola de Nefrolog&#237;a-Sociedad Espa&#241;ola de Medicina Familiar y Comunitaria &#40;S&#46;E&#46;N&#46;-SEMFyC&#41; de 2008&#46; <span class="elsevierStyleBold">Resultados&#58;</span> Del total de 16&#46;814 pacientes incluidos&#44; 3&#46;466 &#40;20&#44;6&#37;&#41; presentaron DM2&#46; En los pacientes con DM2 la prevalencia de ERC seg&#250;n criterios K&#47;DOQI fue del 34&#44;6&#37; &#40;IC 95&#37;&#44; 33-36&#44;2&#41;&#46; El eFG &#60;60 ml&#47;min&#47;m<span class="elsevierStyleSup">2</span> se registr&#243; en el 25&#44;2&#37; de los pacientes con&#160;DM2&#44; siendo en este subgrupo la prevalencia de micro-macroalbuminuria del 31&#44;7&#37;&#46; Cumplieron criterios de remisi&#243;n a consultas de nefrolog&#237;a 104&#160;pacientes con DM2 &#40;3&#37;&#41; y 132&#160;sin DM2 &#40;1&#37;&#41; &#40;p &#60;0&#44;0001&#41;&#46; <span class="elsevierStyleBold">Conclusiones&#58;</span> La prevalencia de DM2 en los centros de salud es elevada&#44; con frecuente presencia de ERC y micro-macroalbuminuria asociada&#46; Un porcentaje significativo de pacientes cumple los criterios de remisi&#243;n consensuados S&#46;E&#46;N&#46;-SEMFyC&#46; La colaboraci&#243;n con atenci&#243;n primaria es fundamental en la detecci&#243;n precoz y seguimiento de esta enfermedad&#44; de tal forma que en cada &#225;rea de salud debe protocolizarse el seguimiento conjunto&#44; con unos objetivos que deben cumplirse en funci&#243;n del estadio de ERC&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Introduction&#58;</span> The frequency and clinical impact of chronic kidney disease &#40;CKD&#41; in type 2 diabetes patients &#40;DM2&#41; and the benefits of early intervention highlights the need for close collaboration in detection and management between Nephrology and Primary Health Care&#46; <span class="elsevierStyleBold">Objective&#58;</span> Our objectives were to estimate the prevalence of CKD in DM2 patients controlled by primary care and evaluate the need to early referral of CKD DM2 patients to renal specialists <span class="elsevierStyleBold">Material and methods&#58;</span> Study population&#58; patients older than 18 years of age&#44; with analysis made for any reason in the 16 Health Centers of Health Sector Alca&#241;iz &#40;84&#44;340 inhabitants&#41; during 2008&#46; Variables&#58; age&#44; sex&#44; serum creatinine&#44; urine albumin&#47;creatinine ratio&#44; glycated hemoglobin&#44; potassium and hemoglobin&#46; We calculated the estimated glomerular filtration rate &#40;eGF&#41; by the MDRD formula&#46; We reviewed the Consensus Document S&#46;E&#46;N&#46;-SEMFyC ERC 2008 criteria for referral to renal specialists&#46; <span class="elsevierStyleBold">Results&#58;</span> Of the 16&#44;814 patients enrolled&#44; 3&#44;466 &#40;20&#46;6&#37;&#41; had DM2&#46; In DM 2 patients&#44; the prevalence of CKD was 34&#46;6&#37; &#40;IC 95&#37;&#44; 33-36&#46;2&#41;&#46; eGF &#60;60 ml&#47;min&#47;m<span class="elsevierStyleSup">2</span> was recorded in 25&#46;2&#37; of DM2 patients&#46; In this subgroup the prevalence of albuminuria was 31&#46;7&#37;&#46; Met criteria for referral to renal specialists 104 &#40;3&#37;&#41; DM2 patients and 132 &#40;1&#37;&#41; non diabetic patients &#40;p &#60;0&#46;0001&#41;&#46; <span class="elsevierStyleBold">Conclusions&#58;</span> The prevalence of DM2 in the Health Centers is high&#44; with frequent presence of CKD and albuminuria&#46; An important percentage of patients meets the referral S&#46;E&#46;N&#46;-SEMFyC criteria&#46; The collaboration with primary care is essential in early detection and monitoring of these patients&#44; and common primary care and nephrology protocols are need&#46;</span></p>"
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