The exact reasons why kidney failure causes heart disease, and vice versa (the cardiorenal syndrome) is still incompletely understood [7], although CKD and diabetes share many of the mechanisms causing accelerated vascular aging [8]. It has been argued that diabetes is a cardiovascular disease [9], and similar arguments apply in the case of CKD [6]. In recent years CKD has emerged as a factor of equal importance as diabetes for future cardiovascular events [10–14]. Furthermore, patients with simultaneous comorbidities have a markedly increased risk. For instance in the Study of Heart and Renal Protection (SHARP), despite similar GFR, patients with diabetes had an adjusted risk of death two-fold higher than that those with cystic kidney disease alone (relative risk 2.35) [15].

In acute coronary syndromes, the single most common cause of death worldwide [1], approximately 40 % of the patients have at least moderate kidney dysfunction with an eGFR below 60 mL/min/m² [16]. The 1-year-mortality among these is about 25 %, compared to 5 % in patients with normal renal function [16]. The increased mortality in CKD patients after an acute coronary event is directly related to decreasing kidney function [10, 14]. This may in part be due to the fact that patients with kidney dysfunction are receiving less active treatment, such as with early revascularisation [17], but may also be caused by a range of disturbances in for instance haemostasis and vascular function [8, 18]. The lack of guidelines can be attributed to limited clinical data, as the majority of randomised trials in acute coronary syndromes so far have excluded CKD patients [19].

Thus, patients with concomitant cardiovascular disease, renal dysfunction and diabetes are despite their high risk and high health care consumption often not optimally treated, since an increasingly specialised medical care too often treat these diseases in separate silos. Current studies and guidelines follow the same pattern.

In medicine, multidisciplinary care used to refer to physicians in different specialities working together to provide the most comprehensive treatment plan for the patients. The term multi-professional used to refer to different professional categories, such as physicians, nurses, physiotherapists and pharmacists, working together. However, in recent years this distinction has dissolved and the most commonly used term is multidisciplinary. Both involve combining two or more disciplines into the task at hand; i.e. the intervention.

The chronic nature of CKD has led the nephrology speciality to early recognise the importance of multidisciplinary intervention. For instance nurse practitioners have taken a large active part in dialysis treatment since the early days [20].

In dialysis patients, a comparison of outcomes between Canada and Italy suggests that despite equal and long exposure to nephrology care prior to dialysis, there appears to be an association of survival advantage for patients exposed to formalized multidisciplinary clinic programmes in addition to standard nephrologists’ follow-up [21]. By multidisciplinary they here refer to a team of a nurse educators, nephrologists, social workers, nutritionists, and pharmacists. In the nephrology setting it is important to note that these integrated clinics are usually instigated with the underlying objective of facilitating and prepare patients for renal replacement therapy. However it appears they are sometimes also effective in reducing renal decline.

Cohort studies in CKD suggest that similar integrated, multidisciplinary clinics based on a nephrologist and a team with other professions are associated with improvements in metabolic and BP control [22, 23]. Multidisciplinary clinics are also associated with a slower decline in GFR than usual care [24], and a significant reduction in the risk for all-cause mortality [23, 25].

Results from randomised trials are less clear. Barrett and co-workers randomised 474 patients with median eGFR of 42 mL/min to either standard care by a general practitioner, or care by a nurse-coordinated team including a nephrologist. Guided by protocols, the intervention team targeted risk factors for adverse kidney and cardiovascular outcomes. Over a median of 24 months, the nurse-coordinated team did not affect rate of GFR decline or control of most risk factors compared with usual care [26]. In another trial (the MASTERPLAN study), 788 patients with moderate to severe CKD were randomised to receive nurse practitioner support added to physician care, or physician care alone. Median follow-up was 5.7 years, and the intervention reduced the incidence of the composite renal endpoint by 20 %, and decreased the decline in eGFR by 0.45 mL/min per year compared with the control group [27].

Taking these data in consideration, nephrology guidelines state that people with progressive CKD should be managed in a multidisciplinary care setting, with access to education and counselling [28]. Again, these interventions are aimed at facilitating and prepare patients for transplantation and dialysis, but have been shown to delay renal decline on their own. The specific components for CKD models of care should include protocols for laboratory and clinic visits, attention to cardiovascular co-morbidities and CKD-associated co-morbidities such as anaemia, a vaccination program, an education program which includes both general CKD and renal replacement therapy, education, self-management, lifestyle modification including diet, exercise, and smoking cessation, counselling and support for factors such as social bereavement, depression, and anxiety [28–30].

The details on how to best achieve all these components, particularly in patients with multiple co-morbidities is yet to be determined.

With proper consideration of the fundamentals of treatment and team-approach, there can be life added to the years and years to the lives of our increasing diabetic population. W. Pote Jr, California, 1958 [31]

Patients with diabetes are living an average of 8.5–10 years shorter than non-diabetics, and it is particularly cardiovascular disease that leads to premature death [32]. Treatment studies in diabetes have traditionally focused primarily on blood sugar control, and secondarily on the most common risk factors like high blood pressure or lipids. However, it is clear that a multifactorial approach is required to achieve clinically relevant treatment effects [32, 33]. An excellent example of how efficient a multidisciplinary approach can be when implemented rigorously is the STENO-2 study [33]. By multidisciplinary they refer to a combined clinic with an endocrinologist, nurse practitioner, dietician and physiotherapists. The intervention group received aspirin, optimized treatment on glycaemic control, blood pressure, dyslipidemia, and comprehensive lifestyle intervention with both diet and exercise. The intervention not only halved the risk of nephropathy and retinopathy, but also halved the absolute risk of death over 13 years. STENO-2 included only type-2 diabetes patients, and excluded all with concomitant heart disease or kidney failure, notwithstanding their higher risk.

Despite the well established strong link between cardiovascular disease and diabetes, approximately 30–40 % of those with diabetes have undiagnosed cardiovascular disease [32]. It is not uncommon that first when the patient suffer a heart attack or stroke, it is found that they have type 2 diabetes.

More than 80 % of all cardiovascular deaths can be delayed using changes in life-style and commonly prescribed drugs [34]. There is very good evidence for a range of measures to reduce the risk of both morbidity from cardiovascular disease and relapse in established cardiovascular disease [35]. There is consensus that all these measures should be carried out simultaneously. Despite this, many patients never receive the full benefits from these interventions due to frequent under-diagnosis, late presentation and under-treatment [36, 37]. This is particularly an issue for subjects with complex diseases.

In cardiology, the most studied and developed area is integrated heart failure clinics. It was early recognised that nurse-directed, multidisciplinary intervention improves quality of life, reduce hospital use and medical costs for patients with congestive heart failure [38, 39]. Following studies have also shown that multidisciplinary strategies for the management of heart failure patients also improve survival [38, 40]. Multidisciplinary in this setting also refer to clinics with cardiologists, nurse practitioners, physiotherapists, social workers and sometimes pharmacists.

“Holistic management” is currently a class IA recommendation in the European Society of Cardiology. The guidelines specify that the management should include not only optimised medical treatment but also patient education, social support, exercise training, patient monitoring, and palliative care in a multidisciplinary management programme [41].

The same set of measures, although under somewhat different labels, are also recommended in the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines AHA/ACCF [42]. They further endorse a set of patient-centered practices for care coordination from the National Quality Forum [43]. The statement detail comprehensive specifications for successful care coordination for patients and their families.

Patients with concomitant cardiovascular disease, renal disease and diabetes represent a large proportion of all patients in cardiology, nephrology and diabetology. A progressively increased subspecialisation has led to that the cardiologist treats the heart, nephrologists the kidneys and endocrinologists’ diabetes. At best, this causes the patient to spend substantial time visiting multiple specialists in each field, and at worst serious under-treatment of co-morbidities. This is not something new; already in 1979 Aldhizer et al. highlighted some of the problems associated with the care of patients with diabetes, with lack of coordination of care, multiple visits, multiple blood works, lack of and sometimes conflicting information, lack of prioritization of treatment goals, redundancy and excessive cost [44]. For the patient, it becomes almost impossible to detail the full medical history and work-up at each visit to a new caregiver, particularly given the shrinking time allotted each visit. Often vital information on previous plans and work-ups are not communicated to all health-care professionals involved in the care for the patient, in many places worsened by flawed IT solutions for medical records.

The amount of healthcare consumed can be phenomenal, as illustrated in Fig. 20.2, showing a not uncommon patient with 480 healthcare contacts during 18 months, not including the assisted living visits. And yet the perceived benefit and care received is not in proportion to the efforts spent [46]. Despite a high indication for optimal treatment, a majority of patients fail to reach basic secondary preventive measures, such as blood pressure [47], and lipid control [46, 48]. Traditional health-care models ascribe this to lack of patient compliance; a term that may imply that the patient and not the physician is at fault. From the patient’s perspective, there is a great need for coordination, collaboration, education and improved care to optimize quality of life and reduce risk of disease progression.

Many institutions are developing chronic disease management programs, as detailed in the previous sections in this chapter. However, the majority focus on a single disease and may not recognise the extent of co-morbidities and the complexity of the diseases in many of these individuals. For example, of those patients who survive an acute myocardial infarction, 40 % have decreased kidney function, 30 % diabetes, and another 30 % impaired glucose tolerance [5].

As awareness of the existence of groups of patients suffering from several co-morbidities has spread, new approaches have been suggested for disease management. Instead of treating these patients separately in three different clinics, it may be possible to develop integrated care units which can gather the competence and organise the care around the patient.

As the number of healthcare professionals, care settings, and treatments involved in a patient’s care has increased, the coordination of care has become both more difficult and more vital. As shown, patients with multiple chronic conditions receive a remarkable amount of health-care recourses. However, in most health-care system, no one is coordinating these interventions [46, 49]. Least of all the patient, who often feel out of control, their daily lives filled with pills, injections, glucose-checks, seeing doctors and nurses, and doing blood works.

Integrated care units is a new way of conducting health care [50]. Pilot studies using this approach have shown potential benefits, but also highlighted many difficulties with changing traditional organisations and physicians way of working [51].

The first multidisciplinary clinic in this area, in the meaning of integrating several specialities, is the Integrated Care Clinic at St. Paul’s Hospital in Vancouver [52]. This clinic brings together medical specialists in nephrology, cardiology and endocrinology, as well as a knowledgeable team of nurses, pharmacists, dieticians and social workers. The goals of the Integrated Care Clinic are to increase communication across the traditional boundaries between different health care professionals and different disciplines, to improve coordination of patient care, to reduce medical appointments and duplicate testing for patients, and to provide more integrated education and self-management for the patient.

This clinic have focused on patients already attending a nephrology clinic and one or two of cardiology or endocrinology, and not aiming at those with unrecognized cardiovascular disease or undiagnosed (pre) diabetes [52]. In this setting, patients were randomised (n = 150) to either standard care, or to the integrated clinic. Mortality, hospitalization rates and progression to end-stage renal disease did not differ and a similar proportions in each group achieved clinical and laboratory targets. Their conclusion was that medical care of complex patients may be delivered in a single combined specialty clinic as compared to multiple disease specific clinics without compromising patient care or important health outcomes, with demonstrable outpatient costs savings [52]. This study did not find any difference in the number of specific symptoms patients reported (such as nausea and vomiting, loss of appetite, muscle cramps etc.), but patient reported outcome measures such as quality of life and empowerment were not reported.