Heart-kidney-endocrine joint multidisciplinary cooperation to manage patients with chronic diseases

With the renewal and development of modern medicine and the continuous refinement of the field of diseases, specialized disease treatment has become the main diagnosis and treatment model in various hospitals in our country
.

However, for patients with chronic diseases, such as patients with type 2 diabetes (T2D), chronic kidney disease (CKD) and chronic heart failure, the incidence of common diseases among various diseases is relatively similar, and each disease is a complication of each other.
Clinical diagnosis and treatment usually involve multiple disciplines
.

Therefore, for patients with chronic diseases, multidisciplinary collaborative management (MDT) is a new model of medical management
.

1.
The definition and growth history of MDT1,2 In the 1970s, the United States first proposed the concept of "integrated medicine", which is the precursor of MDT
.

MDT usually refers to the formation of a relatively fixed medical team by at least two experts in related disciplines to communicate on the diagnosis and treatment of a specific patient group on a regular basis and at a fixed point, provide patients with comprehensive treatment plans and participate in the management mode of diagnosis, treatment and nursing
.

Unlike specialists, MDT treats patients as a whole and provides them with the best individualized diagnosis and treatment, which is a more reasonable and successful intervention method for chronic diseases
.

At present, various domestic units have been exploring MDT for many diseases, and have achieved good results in diagnosis and treatment
.

2.
MDT basis for the combination of heart-kidney-endocrine ● Heart + kidney = cardiorenal syndrome 3 Cardiorenal syndrome (CRS) refers to the acute or chronic dysfunction of one of the heart or kidney causing the acute or chronic of the other organ Dysfunction
.

CRS can be divided into cardio-renal syndrome and renal-cardiac syndrome according to what is the first driving factor of heart and kidney
.

● Heart + endocrine = various heart system diseases 4 Diabetes and abnormal glucose metabolism are independent risk factors for cardiovascular events such as acute coronary syndrome (ACS), chronic coronary syndrome (CCS) and heart failure (HF), blood sugar Poor control can lead to poor prognosis of coronary syndrome and increase the risk of HF hospitalization, all-cause death, and cardiovascular death
.

● Kidney + endocrine = anemia, calcium and phosphorus metabolism disorders, diabetic nephropathy 5 Diabetic kidney disease (DKD) refers to CKD caused by diabetes, which is one of the main microvascular complications of diabetes
.

Complications include increased blood pressure, excessive volume load, electrolyte imbalance, metabolic acidosis, anemia, and metabolic bone disease
.

● Heart + kidney + endocrine = chronic heart failure, CKD combined with cardiovascular disease, diabetes and its complications, etc.
Chronic heart failure 6: A set of complex clinical complexes that cause ventricular filling or impaired ejection ability due to any abnormal cardiac structure or function Levy
.

The main clinical manifestations are dyspnea and fatigue (restricted activity tolerance) and fluid retention (pulmonary congestion and peripheral edema)
.

HF is a serious manifestation or late stage of various heart diseases, and the mortality and rehospitalization rate remain high
.

CKD combined with cardiovascular disease7: Cardiovascular disease (CVD) is the first cause of death in patients with CKD; 7.
6% of patients who died of CVD combined with CKD.
CKD and CVD often coexist and further affect the survival rate of patients
.

Diabetes and its complications 8: Diabetes is one of the most common chronic diseases, with a global prevalence of 9.
3%.
The harm it brings is systemic, including diabetic cardio-cerebrovascular accidents, diabetic retinopathy, and diabetic peripheral neuropathy and so on
.

3.
A frequent visitor of MDT-multidisciplinary collaboration for common chronic diseases ● Multidisciplinary collaboration for diabetes management 3 Diabetes management not only needs to strengthen blood sugar management, but also emphasizes the management of heart and kidney complications
.

The incidence of cardiovascular and cerebrovascular accidents in diabetic patients is 2 to 4 times higher than that of healthy people.
Diabetic retinopathy is the first in blinding retinal vascular disease, and diabetic peripheral neuropathy is the main cause of non-traumatic distal limb amputation; in addition, 30%-40% of patients with type 2 diabetes (T2D) suffer from diabetic nephropathy (DKD), and the prevalence of DKD also increases proportionally with the significant increase in the prevalence of diabetes
.

Therefore, the prevention and treatment of diabetes and its complications requires the collaboration of multiple disciplines such as endocrinology, nephrology, cardiology, neurology, and ophthalmology
.

● Multidisciplinary collaborative management of chronic heart failure5,6 The management of heart failure includes the treatment and prevention of heart failure and its complications
.

Heart failure can cause a variety of complications, among which renal dysfunction is an important complication.
The two are mutually causal and amplify the pathological damage effect
.

Moreover, the heart has endocrine functions due to endocrine natriuretic peptides
.

Heart failure has significantly increased the secretion of natriuretic
.

Similarly, the kidneys also have endocrine functions due to the endocrine function of 1,25-dihydroxycholecalciferol, renin, renin prostaglandin and erythropoietin
.

In HF, the secretion of prostaglandin and kinin decreases, which affects the decrease of sodium and water excretion and aggravates edema
.

The treatment of heart failure requires a multidisciplinary team composed of cardiologists, general practitioners, rehabilitation physicians, psychologists, clinical pharmacists, nutritionists, and nurses to provide long-term and comprehensive drug and non-drug education and management to patients
.

In addition, the prevention of heart failure is mainly for multidisciplinary education and management of high-risk groups such as hypertension, hyperlipidemia, diabetes, the elderly, and obesity.
Risk factors are strictly controlled to delay or reduce the risk of heart failure
.

Therefore, the MDT model is an applicable model for the management of heart failure diseases
.

● Multidisciplinary collaborative management of CKD 4 (cardiorenal syndrome types 3, 4, 5) Diabetes, hypertension, and glomerulonephritis are the most common causes of CKD in China
.

Compared with non-CKD population, the incidence of cardiovascular disease in CKD patients is significantly higher; therefore, preventing cardiovascular events in CKD patients, preventing renal function decline and managing cardiovascular diseases in CKD patients are important parts of disease management
.

At the same time, 3%~11% of CKD patients have electrolyte abnormalities due to the decrease in eGFR.
Due to the decrease in EPO production, 41% of CKD patients have reduced hemoglobin levels (male <130g/L, female <120g/L); due to 1,25-dihydroxyl Cholecalciferol secretion is reduced, and bone-mineral disorders are also common in patients with moderate to severe CKD
.

It is suggested that the decline of endocrine function caused by the decline of renal function will give rise to more complications
.

Therefore, the prevention and treatment of CKD and its complications also requires multidisciplinary cooperation such as nephrology, cardiology, endocrinology, hematology and even surgery
.

4.
MDT example-multidisciplinary collaborative management path of diabetic nephropathy 3 Objective: On the basis of strengthening blood sugar, blood pressure and blood lipid management and treatment of nephropathy, reduce the risk of heart and cerebrovascular diseases, and prevent and treat diabetic peripheral neuropathy and retinopathy
.

Path: Establish a DKD joint outpatient clinic and specialized disease diagnosis and treatment unit, and establish a nephrology department as the mainstay, with a multidisciplinary diagnosis and treatment team composed of experts in endocrinology, cardiology, neurology, and ophthalmology, and conduct joint outpatient clinics every 3 months During follow-up, patients with DKD undergo a systematic examination, evaluation, and treatment plan adjustment in the nephropathy diagnosis and treatment unit every 6 months
.

Especially for newly diagnosed DKD patients, a comprehensive assessment of diabetes-related complications should be carried out first, and corresponding individualized treatment strategies should be formulated
.

DKD's multidisciplinary diagnosis, treatment and management process 5.
Multidisciplinary cooperation to manage patients is a new trend in the future.
If traditional single-disciplinary diagnosis and treatment is to see a doctor, then multidisciplinary collaboration is to see the sick, and truly realize patient-centered treatment Idea
.

In recent years, authoritative guidelines in many fields have suggested multidisciplinary management of diseases, which will be a new trend in chronic disease management in the future
.

●The 2012 KDIGO guidelines recommend that patients with chronic kidney disease should be managed in a multidisciplinary care environment.
The multidisciplinary team should include or be able to provide diet counseling, education and counseling on different RRT models, choice of transplantation options, vascular access surgery, and ethics, Psychological and social care7
.

●The 2020 ADA Diabetes Medical Diagnosis and Treatment Standards suggest that diabetes care should be managed by a multidisciplinary team, which can include primary care doctors, subspecialists, nurse practitioners, physician assistants, nurses, nutritionists, sports experts, and pharmacists , Dentists, podiatrists, and mental health professionals
.

●The 2016 ESC Heart Failure Guidelines emphasized that the management of patients with heart failure should work in a multidisciplinary team consisting of cardiologists, nurses, pharmacists, physiotherapists, surgeons, and psychologists to reduce rehospitalization and death of patients with heart failure Risk 9
.

References 1.
Zhang Huihui, Han Ling, Liu Qin, et al.
Discussion on multidisciplinary collaborative diagnosis and treatment model in deepening hospital discipline construction.
Chinese Hospital Management, 2018, 38(10): 37-38.
2.
Jiang Huiqin, Dong Mei.
Chronic Diseases Nursing status and prospects under the multidisciplinary collaborative model.
Journal of Nursing, 2017, 24(022): 28-31.
3.
Expert group on multidisciplinary diagnosis, treatment and management of diabetic nephropathy.
Expert consensus on multidisciplinary diagnosis, treatment and management of diabetic nephropathy.
General practice clinical medicine And Education, 2020,18(6):484-487.
4.
Chen TK, Knicely DH, Grams ME.
Chronic Kidney Disease Diagnosis and Management: A Review.
JAMA.
2019 Oct 1;322(13):1294-1304.
5.
Morton G , Masters J, Cowburn PJ.
Multidisciplinary team approach to heart failure management.
Heart.
2018 Aug;104(16):1376-1382.
6.
Wang Hua, Yang Jiefu.
Retrospect and prospect of prevention and control of heart failure in China.
Chinese Journal of Cardiovascular Diseases, 2019, 047(009):714-717.
7.
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
8.
2020 American Diabetes Association Standards of Medical Care in Diabetes.
9.
Ponikowski P, et al; ESC Scientific Document Group.
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
2016 Jul 14;37(27):2129-2200.
For reference only by medical and health professionals, not for promotion purposes