Integrating the Novel iCARE Estimated Glomerular Filtration Rate Equation for Youth Living With Type 2 Diabetes Into Care: Program Report.

Abstract

Purpose of the program: Youth living with type 2 diabetes (T2D) have high rates of early kidney disease and progression to kidney failure in early adulthood. Pediatric diabetes clinical practice guidelines have focused on screening for albuminuria and have not included recommendations for estimated glomerular filtration rate (eGFR) evaluation in children. In partnership with patients, families, and community partners, we are implementing a novel eGFR equation for youth with T2D into their diabetes care, with the aim of detecting youth with early kidney disease and providing appropriate interventions to slow disease progression.

Sources of information: The development of such a tool aligned with a priority-setting workshop in 2016, where early detection and prevention of kidney disease were identified as a key priority by people living with kidney disease. In response, our team developed the novel Improving renal Complications in Adolescents with type 2 diabetes through Research (iCARE) eGFR equation, which estimates kidney function over time in youth with T2D, and validated it in a cohort of youth in Colorado (US) and a secondary group of youth in Manitoba (Canada).

Methods: To integrate the tool into clinical care, this study includes 4 separate phases. Phase 1: External validation of the iCARE eGFR equation in a cohort of children with obesity and T2D from Colorado, US, to assess the generalizability of the equation. Phase 2: Readiness Assessment of pediatric endocrinologists (a) quantitative survey in Canada (n = 40) and the United States (n = 75) to assess current practice for screening youth with T2D for diabetic kidney disease (DKD) and (b) qualitative focus groups (4 groups; 2 in Canada [n = 8] and 2 in the United States [n = 5]) to explore barriers and facilitators to implementation of the iCARE eGFR equation into the care for youth with T2D. Focus groups of youth living with T2D are underway and explore how youth and families wish to be educated regarding kidney health and what sources of information would be helpful to empower youth to ask about kidney health in clinical settings. Phase 3: Development and implementation of an iCARE eGFR equation toolkit, which will include the resources for providers and patient education materials and the inclusion of the novel eGFR equation into an app and local electronic medical record systems at 3 sites (Vancouver, Winnipeg, Toronto). Phase 4: Evaluation of the iCARE eGFR implementation toolkit, including audits at 3 centers in Canada, as well as patient and provider satisfaction surveys.

Key findings: Phase 1: The validation study confirmed that the iCARE eGFR performed better than previously published eGFR equations in youth living with obesity and T2D. Relevant metrics were the highest P30 (% of eGFR values that fall within 30% of the measured glomerular filtration rate [GFR]) and the lowest bias. Phase 2: Survey results suggest that providers have strong adherence to existing T2D clinical practice guidelines, focused on albuminuria, but have limited experience and comfort with eGFR equations in general. Focus group discussions identified concerns about insufficient evidence indicating that eGFR metrics in childhood are associated with long-term outcomes and questions about generalizability and external validity. Key facilitators for improving uptake included development of a more comprehensive app or platform that presents eGFR findings in an accessible way for endocrinologists and development of clinical pathway guidelines to support follow-up treatment.

Implications: Findings from phases 1 and 2 will be incorporated into the iCARE eGFR implementation toolkit, such that care providers and patients are able to utilize the most up-to-date evidence to screen for DKD and implement care strategies that will optimize the long-term kidney health of youth living with T2D.