Analysis of the association of multidisciplinary team care and education intervention in patients with early-stage diabetic kidney disease in Taiwan

Abstract

The National Health Insurance Bureau in Taiwan introduced several initiatives to slow the progression of diabetic kidney disease (DKD) through early interventions and comprehensive patient education. This study evaluates the association of a multidisciplinary care and education model for patients with type 2 diabetes mellitus and early-stage DKD in Taiwan. A total of 355 participants enrolled in an integrated care program from May 2022 to September 2023 and followed up until April 2024 were analyzed. The intervention included personalized education, exercise management, dietary counseling, and multimedia tools aimed at improving disease self-management. The results demonstrated that compared to baseline, the patients with second follow-up data had lower systolic blood pressure (p < 0.001), lower diastolic blood pressure (p < 0.001), lower glycosylated hemoglobin A_1c (HbA_1c) (7.51% vs. 7.10%, p < 0.001), lower total cholesterol (p = 0.047), lower high-density lipoprotein cholesterol (p = 0.047), lower low-density lipoprotein (LDL) cholesterol (p = 0.009), lower estimated glomerular filtration rate (p < 0.001), lower log urine albumin to creatinine ratio (p < 0.001), used fewer types of antihypertensive agents (p < 0.001), more types of oral hypoglycemic agents (p = 0.045), more insulin (p < 0.001), and more statins (p = 0.029). These findings showed that the multidisciplinary care model significantly improved glycemic control, blood pressure, lipid profiles, and albuminuria in patients with type 2 diabetes and early-stage DKD. Specifically, reductions in HbA_1c, systolic and diastolic blood pressure, total cholesterol, LDL-cholesterol, and albuminuria were achieved, underscoring the importance of a comprehensive team-based approach.

Graphical Abstract

Introduction

Diabetes mellitus is a widespread and growing public health concern both globally and in Taiwan [1, 2]. It is characterized by chronic hyperglycemia due to insulin resistance or impaired insulin secretion, leading to significant complications if not well managed [3]. Approximately 10% of adults worldwide are affected by diabetes (approximately 530 million people), a figure that is predicted to grow to over 780 million people by 2045 [1]. The steadily increasing prevalence is also a concern in Taiwan [2]. The risk factors for diabetes include genetic predisposition, obesity, sedentary lifestyle, and poor dietary habits [4]. Over time, untreated or poorly managed diabetes leads to complications affecting the cardiovascular, nervous, and renal systems, with increased mortality due to heart disease, stroke, and kidney failure [3]. Early control of blood glucose levels is therefore essential to reduce these risks and prevent further health deterioration.

One of the most pressing diabetes-related complications is diabetic kidney disease (DKD), affecting between 20–40% of individuals with diabetes [5, 6]. This progressive condition not only has a negative effect on the patient’s health and healthcare systems, but also presents significant challenges to public health policies. In Taiwan, the aging population and rising prevalence of chronic diseases have increased the incidence of DKD, further complicating diabetes management [7]. Previous studies have demonstrated that early interventions including stringent control of blood glucose [8], blood pressure, and proteinuria can effectively delay the progression of DKD [3, 9].

In Taiwan, DKD is the leading cause of end-stage renal disease necessitating dialysis [7]. To address this issue, the National Health Insurance (NHI) Bureau in Taiwan introduced several initiatives, including the “Diabetes Care Improvement Project” in 2001 and the “Chronic Kidney Disease (CKD) Early Stage Care Program” in 2011, to slow the progression of DKD through early interventions and comprehensive patient education. More recently, the NHI Bureau launched the “Integrated Diabetes and Early CKD Care Program” in 2022, which emphasizes multidisciplinary cooperation among healthcare professionals such as nephrology educators, endocrinologists, diabetes educators, nutritionists, and hypertension specialists. This program aims to empower patients with early-stage CKD and diabetes through education, nutrition, and lifestyle interventions, ultimately slowing the progression of CKD and reducing the need for costly treatments such as dialysis. The program highlights the importance of integrated healthcare and collaborative strategies to improve outcomes, reduce healthcare costs, and enhance patients’ quality of life. The aim of this study was to evaluate the association of this multidisciplinary care and education model for patients with type 2 diabetes mellitus and early-stage DKD in Taiwan.

Subjects and methods

Previous studies have demonstrated that multidisciplinary team care models play a crucial role in improving outcomes among patients with diabetes and chronic kidney disease. Diabetes self-management education enhances patients’ disease knowledge and adherence to lifestyle modifications [10], while nutritional counseling focusing on individualized diet planning contributes to better glycemic and lipid control [11]. Structured exercise interventions have been associated with improved insulin sensitivity, blood pressure regulation, and cardiorespiratory fitness [12]. Moreover, pharmacist- or nurse-led medication adherence programs effectively reduce therapeutic inertia and improve treatment compliance [13]. Collectively, these findings underscore the importance of a multidisciplinary, patient-centered approach in optimizing metabolic and renal outcomes in diabetes care.

Study population

Patients with type 2 diabetes who were receiving hypoglycemic agents, had a glycosylated hemoglobin A_1c (HbA_1c) level of ≥6.5%, and who were enrolled in an integrated care plan for diabetes and early-stage CKD between May 2022 and September 2023 were included in this study. All of the included patients were followed up until April 2024. Following enrollment, the patients were scheduled to receive two follow-up visits every 4 to 6 months, during which they underwent blood, urine, and physical examinations. Individuals with incomplete data were excluded, including 10 at baseline, 43 at the first follow-up, and 124 at the second follow-up. Subsequently, a total of 355 patients were enrolled in the study (Fig. 1). The observation period was 8.5 ± 2.0 months.

Fig. 1. Flowchart of study population. Patients enrolled in an integrated care plan for diabetes and early-stage CKD between May 2022 and September 2023 were included in this study. All of the included patients were followed up until April 2024. Following enrollment, the patients were scheduled to receive two follow-up visits every 4 to 6 months, during which they underwent blood, urine, and physical examinations. After case enrollment, data were collected and individualized education was provided covering the patient’s understanding of self-management, medication adherence, and attitudes toward exercise. Differences between time points (baseline, first follow-up, and second follow-up) were assessed.

Before the consultation, the patients were asked to complete measurements of blood pressure, weight, and fingertip blood glucose. During the consultation, the physician ordered relevant tests based on the patient’s condition. For newly diagnosed patients, the assessment was conducted by a physician certified by the “Diabetes Shared Care Network.” After the consultation, if the patient met the criteria for case enrollment and provided consent, the clinic nurse took them to the diabetes, kidney and nutrition education rooms. After case enrollment, data were collected and individualized education was provided covering the patient’s understanding of self-management, medication adherence, and attitudes toward exercise.

The collected data included body mass index, age, sex, diabetes duration, and the presence of hypertension, coronary artery disease and cerebrovascular disease. Overnight fasting blood and urine samples were also obtained and examined using an autoanalyzer (Roche Diagnostics GmbH, D-68298 Mannheim COBAS Integra 400) to collect data on HbA_1c, triglycerides, total cholesterol, high-/low-density lipoprotein (HDL/LDL) cholesterol and estimated glomerular filtration rate (eGFR) (using the 4-variable Modification of Diet in Renal Disease equation [14]). Urine albumin and creatinine were measured from a spot urine sample also using the COBAS autoanalyzer (Roche Diagnostics). Data on blood pressure were obtained, with the measurements made digitally. The patients were requested to avoid caffeine, exercise, and smoking for a minimum of 30 minutes prior to the measurements.

Assessment of alcohol drinking and cigarette smoking history

All of the participants also underwent a face-to-face interview with a researcher, during which they completed a questionnaire asking about alcohol drinking and cigarette smoking history. The definition was defined as previously published [15].

Multidisciplinary team care and education

The multidisciplinary team care and education program included four areas covering patient knowledge education and equipment, multimedia messaging, exercise management, and improving medication adherence, as described below.

A. Patient Knowledge Education and Equipment

1. Printed Educational Materials: (1) Insulin Flipbook: This interactive booklet was created by educators and lists common misconceptions, myths, and challenges about insulin injections. The front side presents questions, while the back provides answers. (2) Carbohydrate Food Brochure: Dietitians designed this visual, colorful handout using a “Ferris wheel” concept to showcase a variety of foods. Real food images illustrate portion sizes and calories. (3) Food Grid Game: Inspired by the Monopoly board game, dietitians created a “Food Grid Game” with nutrition question and answer cards to assess the patients’ dietary understanding. (4) Simplified Recipe Guide: Dietitians developed a color recipe book using easily accessible ingredients, with nutritional analyses for the patients’ reference. (5) Convenience Store Portion Labels: Dietitians coordinated with the hospital’s convenience store to label portion sizes on food items for the patients’ reference.

2. Simulated Insulin Injection Demonstration: For patients who were reluctant to inject insulin, educators provided a simulated injection demonstration to alleviate needle anxiety.

3. “30-Day New Life Mood Journal”: This health education booklet was designed through brainstorming and a literature review, and addresses disease control, complications, and screenings, with encouraging phrases and daily glucose management tips. The introduction features a health declaration by an endocrinologist reminding the patients of the importance of disease control.

4. Kahoot! Interactive Game: The team designed a 10-question quiz and downloaded Kahoot! to tablets. Interactive quizzes were then used to boost the patients’ focus, learning motivation, and disease awareness. Learning outcomes were assessed before and after testing.

5. Outpatient Group Education Sessions: After discussion, the team increased the frequency of group education sessions from quarterly to monthly, using waiting areas during endocrinology and nephrology outpatient hours to conduct disease care and nutritional education.

B. Multimedia Messaging

1. Community Medical Group Information Collection: Information on community medical groups collaborating with the hospital was categorized by region and stored in the education room.

2. Multimedia Educational Videos: (1) Holiday Diet: Dietitians produced short videos illustrating traditional holiday foods with real images and subtitles for a multi-sensory experience. (2) Exercise Routines: Educators and occupational therapists developed 3–5 minute videos in Mandarin and Taiwanese showcasing exercises of various intensities. The videos can be accessed via QR codes displayed on posters and online.

3. Patient Activity Information Compilation: Educators gathered information on “National/Kaohsiung Diabetes Support Group” activities monthly and displayed it in the clinic and education room.

4. LINE@ Account: LINE is the most popular communication platform in Taiwan (https://www.line.me/). The team created a LINE@ account called “Diabetes with Early-Stage Nephropathy Care,” focusing on blood sugar control, disease, diet, and exercise. A QR code for the account is included in the “30-Day New Life Mood Journal” for easy patient access.

C. Exercise Management

1. Exercise Prescription Planning: Educators collaborated with the head of occupational therapy to design moderate-to-high intensity exercises based on the patients’ physical ability and available resources, with the prescription recorded in the medical records.

2. Monthly Exercise Journal: Educators created a colorful monthly exercise journal with six mascot-themed stickers. The patients placed a sticker in the journal each day they complete their exercise.

3. Planning an In-Hospital Exercise Space: Educators reviewed studies on stationary cycling as moderate-intensity aerobic exercise. After discussion with hospital administrators, a designated area was made available for the study patients, and usage guidelines were provided.

D. Improving Medication Adherence

1. Telephone Medication Reminders: The patients received five daily calls during the first week to remind them to take their medication. Afterward, adherence was evaluated using a medication adherence scale, with reminders continuing 5 days a week for up to 1 month if necessary.

Furthermore, the multidisciplinary team maintained regular communication with the treating physicians. After each education or follow-up session, educators and nutritionists documented patient progress, adherence, and concerns in the hospital’s electronic medical record system. These reports were reviewed by endocrinologists and nephrologists before subsequent consultations. When educators identified inadequate glycemic control, elevated blood pressure, or medication-related issues, they provided feedback directly to the treating physician through the internal communication system, allowing timely medication review and adjustment during the next clinic visit.

All pharmacologic adjustments, including initiation or dosage modification of antihypertensive agents, oral hypoglycemic agents, insulin, or statins, were initiated solely by the treating physicians based on the patients’ clinical and laboratory data. Educators provided feedback to physicians regarding adherence or adverse effects, but final decisions regarding medication changes were made by physicians during clinic visits in shared discussion with patients. Patients were informed about the treatment rationale and retained the right to decline or request alternative adjustments.

Ethics statement

The study protocol was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (KMUHIRB-E(I)-20240375). Due to the retrospective nature of the study, the Institutional Review Board of Kaohsiung Medical University Hospital waived the need for obtaining informed consent. The study was conducted according to the Declaration of Helsinki.

Statistical analysis

All statistical analyses were performed using SPSS 25.0 for Windows (IBM Inc., Armonk, NY). Data were expressed as percentages or mean ± standard deviation. Differences between time points (baseline, first follow-up, and second follow-up) were assessed using the McNemar’s test for categorical variables and paired sample t-test for continuous variables. Linear regression analysis was used to identify the association between medications (sodium-glucose cotransporter-2 inhibitors [SGLT2i] and glucagon-like peptide 1 agonists) and Δ blood pressure, Δ body mass index, Δ laboratory data. Δ means the value of 2nd follow-up minus baseline. Statistical significance was set at p < 0.05.

Results

Baseline clinical characteristics of all patients

The baseline clinical characteristics of the patients are shown in Table 1. The mean age of the 355 patients (189 males and 166 females) was 63.0 ± 12.8 years. Overall, 20.9% of the patients had a history of smoking, 10.2% had a history of drinking alcohol, and 83.4% had diabetes for >5 years. The prevalence rates of hypertension, coronary artery disease, and cerebrovascular disease were 73.2%, 9.0%, and 3.7%, respectively. The baseline usage of antihypertensive agents (including angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers, beta-blockers, calcium channel blockers, diuretics, alpha-1 blockers and alpha-2 agonists), oral hypoglycemic agents (including biguanides, sulfonylurea, dipeptidyl peptidase-4 inhibitors, SGLT2i, thiazolidinedione and alpha-glucosidase inhibitors), insulin, glucagon-like peptide 1 agonists, and statins is presented in Table 1.

Table 1. Baseline clinical characteristics among study patients.

Parameters	Overall (n = 355)
Age (year)	63.0 ± 12.8
Male (%)	53.2
Smoking history (%)	20.9
Alcohol history (%)	10.2
DM duration >5 years (%)	83.4
Hypertension (%)	73.2
Coronary artery disease (%)	9.0
Cerebrovascular disease (%)	3.7
Antihypertensive agents
ACEI and/or ARB use (%)	54.9
Beta-blockers use (%)	19.4
Calcium channel blockers use (%)	45.9
Diuretics use (%)	13.5
Alpha-1 blockers use (%)	5.1
Alpha-2 agonists use (%)	0.8
Oral hypoglycemic agents
Biguanides use (%)	77.7
Sulfonylurea use (%)	45.6
Dipeptidyl peptidase-4 inhibitors use (%)	52.1
Sodium-glucose cotransporter-2 inhibitors use (%)	34.9
Thiazolidinedione use (%)	27.0
Alpha-glucosidase inhibitors use (%)	7.9
Insulin use (%)	24.8
Glucagon-like peptide 1 agonists (%)	4.2
Statin use (%)	76.6

Abbreviations: DM, diabetes mellitus; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin II receptor blocker.

Comparison of clinical characteristics at different time points

Comparisons of clinical characteristics between the patients at the three time points are shown in Table 2. Compared to baseline, the patients with first follow-up data had lower systolic blood pressure (p = 0.001), lower diastolic blood pressure (p < 0.001), lower HbA_1c (7.51% vs. 7.18%, p < 0.001), lower LDL-cholesterol (p = 0.031), lower log urine albumin to creatinine ratio (p < 0.001), used fewer types of antihypertensive agents (p < 0.001), more types of oral hypoglycemic agents (p = 0.011), and more insulin (p < 0.001).

Table 2. Comparison of clinical characteristics between the time cohort.

Parameters	Baseline	1st follow-up	2nd follow-up
Systolic BP (mmHg)	132.13 ± 15.41	128.63 ± 13.64*	127.29 ± 13.27*
Diastolic BP (mmHg)	76.25 ± 9.47	73.73 ± 9.14*	71.87 ± 9.72*†
BMI (kg/m2)	27.95 ± 5.07	27.95 ± 5.11	28.00 ± 4.99
Laboratory parameters
HbA1C (%)	7.51 ± 1.63	7.18 ± 1.21*	7.10 ± 1.25*†
Triglyceride (mg/dL)	131.76 ± 103.97	129.74 ± 78.59	130.92 ± 99.99
Total cholesterol (mg/dL)	153.73 ± 39.72	151.49 ± 37.99	148.19 ± 37.51*†
HDL-cholesterol (mg/dL)	45.47 ± 11.61	45.34 ± 12.40	44.95 ± 11.97*
LDL-cholesterol (mg/dL)	84.74 ± 32.41	80.95 ± 30.07*	80.59 ± 29.37*
eGFR (mL/min/1.73 m2)	73.43 ± 21.62	73.14 ± 22.90	72.02 ± 24.29*†
Log UACR (mg/g)	1.68 ± 0.69	1.66 ± 0.70*	1.64 ± 0.69*†
Medications
Types of antihypertensive agents	2.87 ± 2.16	1.48 ± 1.21*	1.44 ± 1.18*
Types of oral hypoglycemic agents	2.45 ± 1.28	2.53 ± 1.28*	2.53 ± 1.28*
Insulin use (%)	24.8	31.0*	31.5*
Statin use (%)	76.6	78.3	80.3*

*p < 0.05 compared with baseline; ^†p < 0.05 compared with 1^st follow-up.

Abbreviations: BP, blood pressure; BMI, body mass index; HbA_1c, Glycated Hemoglobin A_1c; HDL, high density lipoprotein; LDL, low density lipoprotein; eGFR, estimated glomerular filtration rate; UACR, urine albumin to creatinine ratio.

In addition, compared to baseline, the patients with second follow-up data had lower systolic blood pressure (p < 0.001), lower diastolic blood pressure (p < 0.001), lower HbA_1c (7.51% vs. 7.10%, p < 0.001), lower total cholesterol (p = 0.047), lower HDL-cholesterol (p = 0.047), lower LDL-cholesterol (p = 0.009), lower eGFR (p < 0.001), lower log urine albumin to creatinine ratio (p < 0.001), used fewer types of antihypertensive agents (p < 0.001), more types of oral hypoglycemic agents (p = 0.045), more insulin (p < 0.001), and more statins (p = 0.029).

We have further performed the analysis of medications (SGLT2i and glucagon-like peptide 1 agonists) for Δ blood pressure, Δ body mass index, Δ laboratory data using univariable linear regression analysis (Supplementary Table 1). There is no significance between the two medications and Δ blood pressure, Δ body mass index Δ laboratory data.

Discussion

In this study, we developed and implemented strategies for cross-team care and patient education, supported by interdisciplinary collaboration, to enhance patient knowledge, resources, multimedia messaging and exercise management. This comprehensive approach resulted in a significant reduction in HbA_1c levels, improved blood pressure control (both systolic and diastolic blood pressure) with decreased use of antihypertensive medications, and lower total and LDL-cholesterol and lower albuminuria levels. These outcomes highlight the importance of a coordinated, multi-faceted intervention in improving key health metrics and supporting better disease management for patients.

The first important finding of this study is the significant reduction in HbA_1c levels (7.51% vs. 7.10%) along with the use of more types of oral hypoglycemic agents and insulin. Previous studies have shown that intensified glucose-lowering therapy, including the use of multiple agents and insulin, is effective in reducing HbA_1c levels and delaying the progression of diabetes-related complications, particularly in high-risk populations [16, 17]. The observed HbA_1c reduction in our study aligns with findings from the United Kingdom Prospective Diabetes Study (UKPDS), which demonstrated that improved glycemic control significantly reduced the risk of microvascular complications [18]. Mechanistically, the greater reliance on insulin and additional oral hypoglycemic agents may reflect the progressive decline in beta-cell function, a hallmark of type 2 diabetes, necessitating more aggressive pharmacological interventions over time [19]. Insulin therapy, in particular, directly addresses endogenous insulin insufficiency, while combination therapy targets multiple pathophysiological defects including insulin resistance and hepatic glucose overproduction [19, 20]. However, the need for more aggressive pharmacological interventions underscores the progressive nature of diabetes and the challenges of achieving optimal glycemic control in this population [18]. The multidisciplinary care approach used in this study integrating personalized education, exercise guidance, and dietary modification likely contributed to the improvement in HbA_1c. Beyond pharmacological intensification, several non-drug factors such as enhanced patient education, improved self-monitoring of blood glucose, dietary adjustments, and increased physical activity likely played important roles. Behavioral reinforcement through regular feedback and individualized goal setting may have further promoted better adherence to lifestyle modification, leading to sustained glycemic improvement. Previous studies have shown that structured education programs and lifestyle interventions can enhance medication adherence and empower patients to achieve better glycemic control [10, 11, 21, 22]. Notably, the increased use of insulin and additional oral hypoglycemic agents may reflect a more proactive treatment strategy adopted during the study, which aligns with the recommendations of international guidelines for individualized diabetes management [20]. Despite the positive outcomes, there is also a need to carefully balance glycemic control with potential risks such as hypoglycemia and treatment burden, particularly in patients with advanced age or comorbidities [23].

The second important finding of this study is the significant reductions in systolic blood pressure and diastolic blood pressure along with the use of fewer types of antihypertensive agents. The reduction in the use of antihypertensive medications despite significant improvements in blood pressure levels may be attributed to the non-pharmacological interventions implemented in this study. Previous studies have reported that lifestyle modifications including dietary education emphasizing sodium reduction, exercise prescriptions tailored to individual patient ability, and weight management strategies likely contributed to the improved blood pressure outcomes [11, 24, 25]. Furthermore, the personalized education sessions and regular follow-ups may have enhanced patient adherence to these lifestyle changes, amplifying their effect on blood pressure control [26, 27]. Mechanistically, the improved glycemic control observed in this study may also have played a role in enhancing the blood pressure outcomes. Hyperglycemia is known to exacerbate vascular stiffness and endothelial dysfunction, leading to hypertension progression [28]. Lowering HbA_1c levels can improve endothelial function and reduce oxidative stress, thereby contributing to better blood pressure control [29]. The reduced reliance on antihypertensive agents suggests that an integrated care approach can help mitigate polypharmacy, a significant concern in the management of patients with diabetes and CKD due to their high burden of comorbidities. By minimizing the number of medications required, this approach may reduce the risk of drug interactions, adverse effects, and treatment burden, particularly for older patients [30]. However, it is essential to monitor these patients closely, as tighter blood pressure targets might not be suitable for all individuals, especially those who are frail or have advanced CKD due to the potential risks of hypotension and reduced perfusion to vital organs [31]. Our findings underscore the potential benefits of integrated multidisciplinary care in optimizing blood pressure control for patients with type 2 diabetes and early-stage CKD. Effective blood pressure management is crucial for reducing the risks of both macrovascular and microvascular complications of diabetes, particularly with regards to protecting renal function and reducing cardiovascular mortality [32, 33].

The third important finding of this study is the significant reductions in total and LDL-cholesterol along with the increased use of statins. Statins are well established as the first-line treatment for lowering LDL-cholesterol and reducing cardiovascular risk in patients with diabetes [34]. The observed improvements in lipid profiles in this study align with previous studies demonstrating the efficacy of statins in achieving lipid targets and reducing the risk of cardiovascular events in high-risk populations, including those with diabetes and CKD [35-37]. The increased use of statins in our cohort may reflect adherence to updated clinical guidelines that recommend more intensive lipid-lowering therapy for patients with diabetes and CKD to mitigate their elevated cardiovascular risk [6, 23, 33]. Mechanistically, statins inhibit HMG-CoA reductase, thereby reducing hepatic cholesterol synthesis and upregulating LDL receptors, which enhances the clearance of circulating LDL particles [34]. Beyond the lipid-lowering effects, statins also exert beneficial pleiotropic effects such as reducing inflammation, improving endothelial function, and stabilizing atherosclerotic plaques, which are particularly relevant in diabetes management [38, 39]. These effects may partially explain the observed reductions in both total cholesterol and LDL-cholesterol in this study. Furthermore, the multidisciplinary care model included dietary counseling and medication adherence support, which likely enhanced patient compliance with statin therapy and amplified its clinical benefits [11, 40]. In addition, lifestyle and behavioral interventions—such as improved nutritional literacy, reduced intake of saturated fats, and greater patient awareness of cardiovascular risk—may also have contributed to the observed reductions in LDL-cholesterol. These educational and behavioral components are known to reinforce long-term adherence and optimize lipid management, independent of pharmacologic therapy [3, 11]. Despite these positive outcomes, it is essential to monitor for potential side effects of statin therapy, particularly in patients with CKD, who may be at a higher risk of statin-associated adverse effects such as myopathy and liver enzyme elevation [41, 42]. Balancing the benefits of intensive lipid-lowering with the potential risks of statin therapy is crucial, especially in older patients or those with multiple comorbidities. The significant improvements in lipid profiles observed in our study highlight the importance of integrating pharmacological and non-pharmacological strategies to achieve optimal lipid management in patients with type 2 diabetes and early-stage CKD. These findings reinforce the role of statins as a cornerstone of cardiovascular risk reduction in this population, while also emphasizing the need for individualized care to balance efficacy and safety [23, 34, 43].

In addition to multidisciplinary education and lifestyle management, recent evidence highlights the reno- and cardio-protective benefits of SGLT2i in patients with type 2 diabetes and CKD. Large-scale randomized controlled trials such as DAPA-CKD, and EMPA-KIDNEY have demonstrated that SGLT2i significantly reduce the risk of kidney disease progression, cardiovascular events, and hospitalization for heart failure, independent of their glucose-lowering effects [44, 45]. The mechanisms include reductions in intraglomerular pressure, improved tubule-glomerular feedback, attenuation of renal inflammation, and decreased oxidative stress [46]. In our study, we further analyzed the association between SGLT2i use and changes in blood pressure, body mass index and laboratory outcomes. However, there were no statistically significant differences, possibly due to the relatively small number of SGLT2i users and the short follow-up duration. As the national integrated care program was launched recently, the duration of SGLT2i exposure in our cohort was likely insufficient to demonstrate measurable renal or cardiovascular benefits. Longer follow-up and larger sample sizes will be needed to further evaluate the impact of these evidence-based pharmacologic interventions within the multidisciplinary care framework.

Interestingly, despite improvements in glycemic, blood pressure, and lipid control, a modest decline in eGFR was observed. This phenomenon may reflect several mechanisms. First, transient hemodynamic changes following improved blood pressure or glycemic control can lead to a physiological “early dip” in eGFR, which has been described as part of the renal autoregulatory response. Second, many patients in this study were prescribed renin–angiotensin system inhibitors or SGLT2i, both of which are known to cause an initial decrease in eGFR due to reductions in intraglomerular pressure, followed by long-term renoprotection [44]. Finally, since most participants had long-standing type 2 diabetes, the modest eGFR decline may also reflect the natural course of diabetic kidney disease despite optimized metabolic control. Longer follow-up is warranted to clarify whether these changes represent hemodynamic adaptation or true renal function decline.

This study did not include a comparison cohort of patients who did not receive multidisciplinary team care at the same time. This was because the integrated diabetes and early CKD care program was implemented hospital-wide beginning in May 2022, after which all eligible patients were enrolled in the same standardized multidisciplinary team education and follow-up pathway. Therefore, patients managed before the program launch were not included due to differences in care models, documentation systems, and data completeness, which could introduce bias if compared retrospectively. However, in 2021, before the program, HbA_1c data of type 2 diabetes patients with outpatient department of Internal Medicine (other than Department of Metabolism and Endocrinology) in a regional hospital in Southern Taiwan were 7.389, 7.310, 7.374 and 7.814% (baseline, 1^st, 2^nd and 3^rd follow-up), which did not show the significance. Although this limits our ability to directly quantify the incremental benefit of multidisciplinary care, previous studies have consistently demonstrated that multidisciplinary interventions improve metabolic and renal outcomes compared with standard physician-centered care. For example, Hayashi et al. reported that team-based diabetes management reduced progression to end-stage kidney disease and cardiovascular events [47], while Molitch et al. found that structured multidisciplinary care significantly improved HbA_1c and blood pressure control in patients with type 2 diabetes and CKD [48]. Our findings therefore complement these reports by demonstrating the effectiveness of a standardized, system-wide multidisciplinary program within the real-world setting of a regional hospital in Taiwan.

There are several limitations to this study. First, this study was conducted in a single hospital, which may limit the generalizability of the findings to other healthcare settings. Second, the study population included only patients with type 2 diabetes and early-stage CKD, so the results may not apply to individuals with advanced CKD or other comorbidities. Third, the study relied on patient-reported data for lifestyle behaviors such as smoking and alcohol consumption, which may be subject to recall bias. In addition, this multidisciplinary team care and education intervention is packaged together; it is not separated. Therefore, we could not know which of them made the greatest contribution. Lastly, while the integrated care model resulted in significant improvements in glycemic control, blood pressure, and lipid profiles, we did not evaluate long-term outcomes such as cardiovascular events or progression to end-stage renal disease. Future studies should address these limitations by including a more diverse patient population, longer follow-up, and broader endpoints.

In conclusion, the multidisciplinary care model implemented in this study incorporating patient education, multimedia messaging, and exercise management, significantly improved glycemic control, blood pressure, lipid profiles, and albuminuria in patients with type 2 diabetes and early-stage CKD. Specifically, reductions in HbA_1c, systolic and diastolic blood pressure, total and LDL-cholesterol, and albuminuria were achieved, underscoring the importance of a comprehensive team-based approach (Graphical Abstract). Through interdisciplinary collaboration, the program successfully enhanced patient knowledge and resources, developed engaging multimedia tools, and promoted regular exercise, contributing to better disease management and reduced reliance on pharmacological interventions. These findings highlight the potential of integrated care strategies to improve outcomes in patients with diabetes and CKD. Future research should explore the scalability of this model in broader populations and its impact on long-term complications and quality of life.

Graphical Abstract.

Clinical trial number

Not applicable.

Ethical approval

The study protocol was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (KMUHIRB-E(I)-20240375). Due to the retrospective nature of the study, the Institutional Review Board of Kaohsiung Medical University Hospital waived the need for obtaining informed consent. The study was conducted according to the Declaration of Helsinki.

Consent to participate

Not applicable.

Consent to publish

Not applicable.

Authors contributions

Conceptualization, methodology, validation, formal analysis, writing—review and editing, and supervision: Y-LO and S-CC. Software and investigation: S-CC. Resources, project administration, and funding acquisition: W-CL and S-CC. Data curation: W-CL, Y-JH, Y-LT, J-FC, H-CM, Y-LH, Y-HC, C-YC, Y-LO and S-CC. Writing—original draft preparation: W-CL and Y-JH. Visualization: Y-LO and S-CC. All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported by Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University Grant (S-113-04).

Conflicts of interest

The authors declare that they have no known competing financial interests.

Availability of data and materials

Due to restrictions placed on the data by the Personal Information Protection Act of Taiwan, the minimal data set cannot be made publicly available. Data may be available upon request to interested researchers. Please send data requests to: Szu-Chia Chen, PhD, MD. Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University.

Supplementary Material

Supplementary Table 1

The association between medications (sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 agonists) and Δ blood pressure, Δ body mass index, Δ laboratory data using univariable linear regression analysis