Guidelines and clinical practice at the primary level of healthcare in patients with type 2 diabetes mellitus with and without kidney disease in five European countries

Diab Vasc Dis Res. 2019 Jan;16(1):47-56. doi: 10.1177/1479164118795559. Epub 2018 Sep 21.


Background: The number of patients with type 2 diabetes mellitus and diabetes mellitus-associated chronic kidney disease varies considerably between countries. Next to differences in genetic as well as life style risk factors, varying practices in medical care delivery might cause this diversity.

Method: The PROVALID study recruited 4000 patients with type 2 diabetes mellitus at the primary level of healthcare in five European countries (Austria, Hungary, The Netherlands, Poland and Scotland). Baseline data were used to describe patient characteristics and compare the adherence to ADA (American Diabetes Association) and KDIGO (Kidney Disease: Improving Global Outcomes) guidelines with respect to metabolic and blood pressure control, use of renin-angiotensin system-blocking agents, statins and acetylsalicylic acid between the countries.

Results: About 34.8% of the population had evidence of diabetes mellitus-associated chronic kidney disease. The median HbA1c level of the cohort was 6.8% (ranging from 6.5 in Poland to 7.0% in Scotland). Mean blood pressure was 136/79 (±17/10) and significantly higher in subjects with elevated albuminuria. These individuals also were more often treated with renin-angiotensin system-blocking agents (74.1% vs 84.6%), whereas the use of statins was driven by cardiovascular comorbidity. Acetylsalicylic acid was used in only 28.9% subjects. Despite similar cardiovascular comorbidities and renal function, the use of renin-angiotensin system-blocking agents varied significantly between the countries from 66.7% to 87.4%. An even higher variability was observed for patients >40 years of age using statins (39.8%-82.7%) and administration of acetylsalicylic acid in patients older than 50 years (5.2%-43.8%).

Conclusion: Our study shows that medical practice in type 2 diabetes mellitus patients with and without renal disease is different in European countries. Longitudinal follow-up will reveal if this diversity affects clinical endpoints.

Keywords: ADA guideline adherence; Diabetes mellitus; KDIGO guideline adherence; diabetic kidney disease.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Biomarkers / blood
  • Blood Pressure / drug effects
  • Diabetes Mellitus, Type 2 / diagnosis
  • Diabetes Mellitus, Type 2 / drug therapy*
  • Diabetes Mellitus, Type 2 / epidemiology
  • Diabetes Mellitus, Type 2 / physiopathology
  • Diabetic Nephropathies / diagnosis
  • Diabetic Nephropathies / drug therapy*
  • Diabetic Nephropathies / epidemiology
  • Diabetic Nephropathies / physiopathology
  • Europe / epidemiology
  • Female
  • Glycated Hemoglobin A / metabolism
  • Guideline Adherence / trends*
  • Health Status
  • Healthcare Disparities / trends*
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Practice Guidelines as Topic*
  • Practice Patterns, Physicians' / trends*
  • Prevalence
  • Primary Health Care / trends*
  • Prospective Studies
  • Renal Insufficiency, Chronic / diagnosis
  • Renal Insufficiency, Chronic / drug therapy*
  • Renal Insufficiency, Chronic / epidemiology
  • Renal Insufficiency, Chronic / physiopathology
  • Renin-Angiotensin System / drug effects
  • Time Factors
  • Treatment Outcome


  • Biomarkers
  • Glycated Hemoglobin A
  • hemoglobin A1c protein, human