CKD risk factors reported by primary care physicians: do guidelines make a difference?

Information needs for GPs on type 2 diabetes in Western countries: a systematic review

BACKGROUND

Most people with type 2 diabetes receive treatment in primary care by GPs who are not specialised in diabetes. Thus, it is important to uncover the most essential information needs regarding type 2 diabetes in general practice.

AIM

To identify information needs related to type 2 diabetes for GPs.

DESIGN AND SETTING

Systematic review focused on literature relating to Western countries.

METHOD

MEDLINE, Embase, PsycInfo and CINAHL were searched from inception to January 2024. Two researchers conducted the selection process, and citation searches were performed to identify any relevant articles missed by the database search. Quality appraisal was conducted with the Mixed Methods Appraisal Tool. Meaning units were coded individually, grouped into categories, and then studies were summarised within the context of these categories using narrative synthesis. An evidence map was created to highlight research gaps.

RESULTS

Thirty-nine included studies revealed eight main categories and 36 subcategories of information needs. Categories were organised into a comprehensive hierarchical model of information needs, suggesting 'Knowledge of guidelines' and 'Reasons for referral' as general information needs alongside more specific needs on 'Medication', 'Management', 'Complications', 'Diagnosis', 'Risk factors', and 'Screening for diabetes'. The evidence map provides readers with the opportunity to explore the characteristics of the included studies in detail.

CONCLUSION

This systematic review provides GPs, policymakers, and researchers with a hierarchical model of information and educational needs for GPs, and an evidence map showing gaps in the current literature. Information needs about clinical guidelines and reasons for referral to specialised care overlapped with needs for more specific information.

Self-rated knowledge and competence regarding the management of chronic kidney disease in primary care: A cross-sectional European survey of primary care professionals

BACKGROUND

Diabetes is a major risk factor for chronic kidney disease (CKD), which is a leading cause of global morbidity and mortality and also associated with substantial costs to healthcare systems. Despite the current best practice standards of care, management of CKD in diabetes in the primary care setting remains an ongoing challenge. Using an online survey, we aimed to assess the self-rated knowledge and competence of primary care professionals involved in the management of CKD in diabetes in the European region.

METHODS

An online anonymous survey was developed by the Primary Care Diabetes Europe research group and administered to primary care professionals involved in managing CKD in diabetes from 23rd March 2022-9 th October 2022. Descriptive statistics were used to summarise questionnaire responses. Factors influencing ability to initiate treatment strategies were evaluated using logistic regression.

RESULTS

A total of 266 respondents (51.9% males) completed the questionnaire. Most respondents were GPs (82.7%) followed by nurses (9.4%). The age of respondents ranged from 25 to 72 years with a median of 51 years. About a third of respondents indicated that they were fully confident in the screening and diagnosis of CKD in diabetes. With regards to CKD presentation, staging and prognosis, 16.5-21.8% of respondents stated they were fully confident in this area; however, about 11% of respondents were not confident on how to predict CKD prognosis using established clinical guidelines. About a third of respondents stated they were confident without support regarding the complications of kidney disease in diabetes and it being a risk multiplier; just a quarter of respondents were fully confident. A third of respondents stated they were fully confident regarding appropriate management strategies for preventing or slowing down the progression of CKD and the initiation of newer agents. In multivariable analyses, confidence in the knowledge of the stages of kidney disease and criteria for the diagnosis of kidney disease were each associated with an increased odds in the confidence to select and initiate appropriate management strategies.

CONCLUSIONS

With regards to almost all aspects of management of CKD in diabetes, only up to a third of primary care professionals stated they are fully confident and are able to teach others; the majority are confident but would like to know more or require extra support. This may be a contributor to the challenges faced in providing optimal CKD care in people with diabetes in the primary care setting. Effective interventions that can promote the uptake of best practice clinical guidelines in primary care are urgently needed.

Nephrologist referrals of older patients with chronic kidney disease in Singapore: a cross-sectional study

BACKGROUND

Chronic kidney disease (CKD) is common in the older population. By 2035, approximately one-quarter of Singapore residents are expected to have CKD. Many of these patients are not referred to nephrologists.

AIM

To compare the characteristics of older patients (aged ≥65 years) with CKD stage ≥3B in the referral and non-referral groups.

DESIGN & SETTINGS

A cross-sectional study in the primary care organisation National University Polyclinics (NUP), Singapore.

METHOD

Retrospective data were extracted from the electronic health records of patients with CKD (aged ≥65 years) with CKD stage ≥3B.

RESULTS

From 1 January-31 December 2018, a total of 1536 patients aged ≥65 years were diagnosed with CKD stage ≥3B (non-referral group = 1179 versus referral group = 357). The mean patient age in the non-referral group (78.4 years) was older than that in the referral group (75.9 years) (P<0.001). Indian older patients were referred more compared with their Chinese counterparts (P = 0.008). The non-referral group was prescribed significantly less fibrate, statins, insulin, sulfonylureas, dipeptidyl peptidase-4 (DPP4) inhibitors, and antiplatelet than the referral group (P<0.05), but only the difference in fibrates remained significant on subsequent multivariate analysis.

CONCLUSION

This study demonstrates that there is a considerable number of older patients with CKD exclusively managed in the primary care setting (n = 1179) and that referrals primarily depend on demographic factors, namely age and ethnic group, rather than medical determinants of CKD severity or case complexity.

Real World Evidence and Clinical Utility of KidneyIntelX on Patients With Early-Stage Diabetic Kidney Disease: Interim Results on Decision Impact and Outcomes

INTRODUCTION AND OBJECTIVE

The lack of precision to identify patients with early-stage diabetic kidney disease (DKD) at near-term risk for progressive decline in kidney function results in poor disease management often leading to kidney failure requiring unplanned dialysis. The KidneyIntelX is a multiplex, bioprognostic, immunoassay consisting of 3 plasma biomarkers and clinical variables that uses machine learning to generate a risk score for progressive decline in kidney function over 5-year in adults with early-stage DKD. Our objective was to assess the impact of KidneyIntelX on management and outcomes in a Health System in the real-world evidence (RWE) study.

METHODS

KidneyIntelX was introduced into a large metropolitan Health System via a population health-defined approved care pathway for patients with stages 1 to 3 DKD between [November 2020 to March 2022]. Decision impact on visit frequency, medication management, specialist referral, and selected lab values was assessed. We performed an interim analysis in patients through 6-months post-test date to evaluate the impact of risk level with clinical decision-making and outcomes.

RESULTS

A total of 1686 patients were enrolled in the RWE study and underwent KidneyIntelX testing and subsequent care pathway management. The median age was 68 years, 52% were female, 26% self-identified as Black, and 94% had hypertension. The median baseline eGFR was 59 ml/minute/1.73 m2, urine albumin-creatinine ratio was 69 mg/g, and HbA1c was 7.7%. After testing, a clinical encounter in the first month occurred in 13%, 43%, and 53% of low-risk, intermediate-risk, and high-risk patients, respectively and 46%, 61%, and 71% had at least 1 action taken within the first 6 months. High-risk patients were more likely to be placed on SGLT2 inhibitors (OR = 4.56; 95% CI 3.00-6.91 vs low-risk), and more likely to be referred to a specialist such as a nephrologist, endocrinologist, or dietician (OR = 2.49; 95% CI 1.53-4.01) compared to low-risk patients.

CONCLUSIONS

The combination of KidneyIntelX, clinical guidelines and educational support resulted in changes in clinical management by clinicians. After testing, there was an increase in visit frequency, referrals for disease management, and introduction to guideline-recommended medications. These differed by risk category, indicating an impact of KidneyIntelX risk stratification on clinical care.

Overcoming Barriers to Implementing New Therapies for Diabetic Kidney Disease: Lessons Learned

As a result of the growing number of patients with type 2 diabetes mellitus, the prevalence of diabetic kidney disease (DKD) has proven to be one of the fastest growing health care challenges globally. Early detection and initiation of appropriate interventions to slow the progression of DKD are impeded by low awareness of the health consequences of DKD, high complexity of care that includes the need for lifestyle modifications, difficulties with adhering to increasingly complicated medication regimens, and low acceptance and application of guideline-directed management. After 2 decades of status quo in the care of patients with DKD, recently approved glucose-lowering agents are promising to transform care by demonstrating slowed DKD disease progression and improved survival. As has been learned over the last 2 decades, multiple barriers exist to the optimal integration and utilization of new therapies to improve kidney outcomes. The health care community, professional societies, and regulatory agencies must join efforts to develop implementation strategies for increasing DKD awareness, detection, and treatment.

Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies

INTRODUCTION

Chronic kidney disease (CKD) is widely prevalent, associated with morbidity and mortality, but may be lessened with timely implementation of evidence-based strategies including blood pressure (BP) control. Nonetheless, an evidence-practice gap persists. We synthesize the evidence for clinician-facing interventions to improve hypertension management in CKD patients in primary care.

METHODS

Electronic databases and related publications were queried for relevant studies. We used a conceptual model to address heterogeneity of interventions. We conducted a quantitative synthesis of interventions on blood pressure (BP) outcomes and a narrative synthesis of other CKD relevant clinical outcomes. Planned subgroup analyses were performed by (1) study design (randomized controlled trials (RCTs) or nonrandomized studies (NRS)); (2) intervention type (guideline-concordant decision support, shared care, pharmacist-facing); and (3) use of behavioral/implementation theory.

RESULTS

Of 2704 manuscripts screened, 73 underwent full-text review; 22 met inclusion criteria. BP target achievement was reported in 15 and systolic BP reduction in 6 studies. Among RCTs, all interventions had a significant effect on BP control, (pooled OR 1.21; 95% CI 1.07 to 1.38). Subgroup analysis by intervention type showed significant effects for guideline-concordant decision support (pooled OR 1.19; 95% CI 1.12 to 1.27) but not shared care (pooled OR 1.71; 95% CI 0.96 to 3.03) or pharmacist-facing interventions (pooled OR 1.04; 95% CI 0.82 to 1.34). Subgroup analysis finding was replicated with pooling of RCTs and NRS. The five contributing studies showed large and significant reduction in systolic BP (pooled WMD - 3.86; 95% CI - 7.2 to - 0.55). Use of a behavioral/implementation theory had no impact, while RCTs showed smaller effect sizes than NRS.

DISCUSSION

Process-oriented implementation strategies used with guideline-concordant decision support was a promising implementation approach. Better reporting guidelines on implementation would enable more useful synthesis of the efficacy of CKD clinical interventions integrated into primary care.

PROSPERO REGISTRATION NUMBER

CRD42018102441.

Translating CKD Research into Primary Care Practice: a Group-Randomized Study

BACKGROUND

Chronic kidney disease (CKD) is common in the primary care setting. Early interventions may prevent progression of renal disease and reduce risk for cardiovascular complications, yet quality gaps have been documented. Successful approaches to improve identification and management of CKD in primary care are needed.

OBJECTIVE

To assess whether implementation of a primary care improvement model results in improved identification and management of CKD DESIGN: 18-month group-randomized study PARTICIPANTS: 21 primary care practices in 13 US states caring for 107,094 patients INTERVENTIONS: To promote implementation of CKD improvement strategies, intervention practices received clinical quality measure (CQM) reports at least quarterly, hosted an on-site visit and 2 webinars, and sent clinician/staff representatives to a "best practice" meeting. Control practices received CQM reports at least quarterly.

MAIN MEASURES

Changes in practice adherence to a set of 11 CKD CQMs KEY RESULTS: We observed significantly greater improvements among intervention practices for annual screening for albuminuria in patients with diabetes or hypertension (absolute change 22% in the intervention group vs. - 2.6% in the control group, p < 0.0001) and annual monitoring for albuminuria in patients with CKD (absolute change 21% in the intervention group vs. - 2.0% in the control group, p < 0.0001). Avoidance of NSAIDs in patients with CKD declined in both intervention and control groups, with a significantly greater decline in the control practices (absolute change - 5.0% in the intervention group vs. - 10% in the control group, p < 0.0001). There were no other significant changes found for the other CQMs. Variable implementation of CKD improvement strategies was noted across the intervention practices.

CONCLUSIONS

Implementation of a primary care improvement model designed to improve CKD identification and management resulted in significantly improved care on 3 out of 11 CQMs. Incomplete adoption of improvement strategies may have limited further improvement. Improving CKD identification and management likely requires a longer and more intensive intervention.

Primary care physicians' perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study

BACKGROUND

Given the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD.

STUDY DESIGN

Mixed methods study.

SETTINGS AND PARTICIPANTS

Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA.

METHODOLOGY

We used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care.

ANALYTIC APPROACH

We conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team.

RESULTS

Of 32 participating PCPs, 31 (97%) had been in practice for >10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care.

CONCLUSIONS

PCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD.

Long-term urinary tract effect of ileal conduit after radical cystectomy compared with bladder preservation: a nationwide, population-based cohort study with propensity score-matching analysis

OBJECTIVE

Ileal conduit urinary diversion (ICUD) is the most common procedure after radical cystectomy. Although complications have been reported, few patients with ICUD and bladder preservation controls have been available for long-term follow-up. This study compared the long-term effect of structural changes after cystectomy with ICUD to that in bladder preservation controls.

DESIGN

A retrospective nationwide cohort study.

SETTING

Data retrieved from the Taiwan National Health Insurance Research Database.

PARTICIPANTS

The National Health Insurance database was explored for patients diagnosed with bladder cancer between 1997 and 2006. Only cancer-free patients without chemotherapy and other types of urinary diversion who lived for >5 years were included in the analysis.

OUTCOME MEASURES

Patient characteristics, comorbidity and postoperative urinary tract disease were statistically analysed and compared. Cox proportional hazards model was used to evaluate the incidence rates of outcomes after adjustment for covariates. Propensity scores analysis was used to balance the clinical parameters between groups. The primary outcomes were postoperative new-onset urinary tract disease such as urinary tract infection (UTI), UTI with septicaemia and chronic kidney disease (CKD), or calculus of kidney and ureter.

RESULTS

There were 11 185 patients included in our cohort, among which 703 (6.3%) and 10 482 (93.7%) patients received ICUD and bladder preservation procedure, respectively. Compared with patients who only underwent a bladder preservation procedure, those who had undergone ICUD after cystectomy were independently associated with postoperative de novo urinary tract disease. Propensity score analysis (1:4) was also performed. ICUD contributed to significantly higher new-onset UTI, UTI with sepsis and CKD (HR=1.30, 3.16, 1.35, respectively) compared with bladder preservation procedure after adjustment for age, gender and comorbidities.

CONCLUSION

ICUD after radical cystectomy was associated with a higher incidence of UTI, UTI with septicaemia and CKD during long-term follow-up than the incidences following a bladder preservation procedure.

The Landscape of Diabetic Kidney Disease in the United States

PURPOSE OF REVIEW

The purposes of this review are to identify population characteristics of important risk factors for the development and progression of diabetic kidney disease (DKD) in the United States and to discuss barriers and opportunities to improve awareness, management, and outcomes in patients with DKD.

RECENT FINDINGS

The major risk factors for the development and progression of DKD include hyperglycemia, hypertension, and albuminuria. DKD disproportionately affects minorities and individuals with low educational and socioeconomic status. Barriers to effective management of DKD include the following: (a) limited patient and healthcare provider awareness of DKD, (b) lack of timely referrals of patients to a nephrologist, (c) low patient healthcare literacy, and (d) insufficient access to healthcare and health insurance. Increased patient and physician awareness of DKD has been shown to enhance patient outcomes. Multifactorial and multidisciplinary interventions targeting multiple risk factors and patient/physician education may provide better outcomes in patients with DKD.

User Requirements for a Chronic Kidney Disease Clinical Decision Support Tool to Promote Timely Referral

BACKGROUND

Timely referral of patients with CKD has been associated with cost and mortality benefits, but referrals are often done too late in the course of the disease. Clinical decision support (CDS) offers a potential solution, but interventions have failed because they were not designed to support the physician workflow. We sought to identify user requirements for a chronic kidney disease (CKD) CDS system to promote timely referral.

METHODS

We interviewed primary care physicians (PCPs) to identify data needs for a CKD CDS system that would encourage timely referral and also gathered information about workflow to assess risk factors for progression of CKD. Interviewees were general internists recruited from a network of 14 primary care clinics affiliated with Brigham and Women's Hospital (BWH). We then performed a qualitative analysis to identify user requirements and system attributes for a CKD CDS system.

RESULTS

Of the 12 participants, 25% were women, the mean age was 53 (range 37-82), mean years in clinical practice was 27 (range 11-58). We identified 21 user requirements. Seven of these user requirements were related to support for the referral process workflow, including access to pertinent information and support for longitudinal co-management. Six user requirements were relevant to PCP management of CKD, including management of risk factors for progression, interpretation of biomarkers of CKD severity, and diagnosis of the cause of CKD. Finally, eight user requirements addressed user-centered design of CDS, including the need for actionable information, links to guidelines and reference materials, and visualization of trends.

CONCLUSION

These 21 user requirements can be used to design an intuitive and usable CDS system with the attributes necessary to promote timely referral.

Early chronic kidney disease: diagnosis, management and models of care

Chronic kidney disease (CKD) is prevalent in many countries, and the costs associated with the care of patients with end-stage renal disease (ESRD) are estimated to exceed US$1 trillion globally. The clinical and economic rationale for the design of timely and appropriate health system responses to limit the progression of CKD to ESRD is clear. Clinical care might improve if early-stage CKD with risk of progression to ESRD is differentiated from early-stage CKD that is unlikely to advance. The diagnostic tests that are currently used for CKD exhibit key limitations; therefore, additional research is required to increase awareness of the risk factors for CKD progression. Systems modelling can be used to evaluate the impact of different care models on CKD outcomes and costs. The US Indian Health Service has demonstrated that an integrated, system-wide approach can produce notable benefits on cardiovascular and renal health outcomes. Economic and clinical improvements might, therefore, be possible if CKD is reconceptualized as a part of primary care. This Review discusses which early CKD interventions are appropriate, the optimum time to provide clinical care, and the most suitable model of care to adopt.

Renal Disease Risk Factors Among Risk Groups Comprised of African American Women With Type 2 Diabetes: A Secondary Analysis

PURPOSE

The purpose of this study was to explore and describe the prevalence of renal disease risk factors and the categorization of renal disease risk groups among African American women with type 2 diabetes mellitus (T2DM) who participated in a self-management and coping skills training intervention. We also explored and described the change in renal disease risk factors within and between risk groups, determining if participation in a culturally relevant coping skills training intervention decreased renal disease risk.

METHODS

This study was a secondary analysis of data from a longitudinal intervention study and included all 109 African American women with T2DM from the primary intervention study. This study examined the prevalence of 4 renal disease risk factors among the women at baseline via descriptive statistics, used cluster analysis to divide the women into risk groups and categorize the risk groups, and also measured the change in risk factors over time among risk groups via mixed modeling.

RESULTS

A majority of the women had a hemoglobin A1C ≥7% (62.39%) and were obese (75.93%). The high-risk cluster displayed clinically significant declines in mean systolic blood pressure, triglycerides, and A1C in both the control and intervention groups, and the intervention was more effective in reducing triglycerides and A1C levels among high-risk participants than low-risk. Overall, the control, high-risk group exhibited the largest declines in systolic blood pressure, triglycerides, and A1C.

CONCLUSIONS

This study displays the importance of acknowledging African American women with type 2 diabetes mellitus (T2DM) at high risk for renal disease in health care settings, which is often overlooked, and realizing that renal disease risk reduction is obtainable.

Improving care coordination between nephrology and primary care: a quality improvement initiative using the renal physicians association toolkit

BACKGROUND

Individuals at risk for chronic kidney disease (CKD), including those with diabetes mellitus and hypertension, are prevalent in primary care physician (PCP) practices. A major systemic barrier to mitigating risk of progression to kidney failure and to optimal care is failure of communication and coordination among PCPs and nephrologists.

STUDY DESIGN

Quality improvement. Longitudinal practice-level study of tool-based intervention in nephrology practices and their referring PCP practices.

SETTING & PARTICIPANTS

9 PCP and 5 nephrology practices in Philadelphia and Chicago.

QUALITY IMPROVEMENT PLAN

Tools from Renal Physicians Association toolkit were modified and provided for use by PCPs and nephrologists to improve identification of CKD, communication, and comanagement.

OUTCOMES

CKD identification, referral to nephrologists, communication among PCPs and nephrologists, comanagement processes.

MEASUREMENTS

Pre- and postimplementation interviews, questionnaires, site visits, and monthly teleconferences were used to ascertain practice patterns, perceptions, and tool use. Interview transcripts were reviewed for themes using qualitative analysis based on grounded theory. Chart audits assessed CKD identification and referral (PCPs).

RESULTS

PCPs improved processes for CKD identification, referral to nephrologists, communication, and execution of comanagement plans. Documentation of glomerular filtration rate was increased significantly (P=0.01). Nephrologists improved referral and comanagement processes. PCP postintervention interviews documented increased awareness of risk factors, the need to track high-risk patients, and the importance of early referral. Final nephrologist interviews revealed heightened attention to communication and comanagement with PCPs and increased levels of satisfaction among all parties.

LIMITATIONS

Nephrology practices volunteered to participate and recruit their referring PCP practices. Audit tools were developed for quality improvement assessment, but were not designed to provide statistically significant estimates.

CONCLUSIONS

The use of specifically tailored tools led to enhanced awareness and identification of CKD among PCPs, increased communication between practices, and improvement in comanagement and cooperation between PCPs and nephrologists.

Evaluating the implementation strategy for estimated glomerular filtration rate reporting in Manitoba: the effect on referral numbers, wait times, and appropriateness of consults

Background

Chronic kidney disease screening using estimated glomerular filtration rate (eGFR) reporting is standard in many regions. With its implementation, many centres have had higher referral rates and increased wait times to see nephrologists.

Objective

Manitoba began eGFR reporting in October 2010. We measured the effect of eGFR reporting on referral rates, wait times, and appropriateness of referrals after an educational intervention.

Design

An interrupted time series design was used.

Setting

This study took place in Manitoba, Canada.

Patients

All referrals to the Manitoba Renal Program in the period prior to eGFR reporting between April 1, 2010 and September 30, 2010 were compared with a post period between January 1, 2011 and June 30, 2011.

Measurements

Data on demographics, co-morbidities, referral numbers and wait times were compared between periods. Appropriateness of consults was also measured after eGFR implementation.

Methods

Prior to eGFR reporting, primary care physicians underwent educational interventions on eGFR interpretation and referral guidelines. Referral rates and wait times were compared between periods using generalized linear models. Chart audits of a random sample of 232 patients in the pre period and 239 patients in the post period were performed.

Results

The pre and post eGFR reporting referral rate was 116 and 152 referrals/month, respectively. Average wait times in the pre and post eGFR reporting was 113 and 115 days, respectively. Non-urgent referral wait times increased by 40 days immediately post reporting, while urgent median referral wait times had a more gradual increase. Despite our intervention, inappropriate consultations post eGFR reporting was 495/790 (62.7%).

Limitations

Our study did not measure the intervention’s success on primary care providers, which may have affected our appropriateness data. Our time series design was not powered to find a statistically significant difference in referral numbers. Residual confounding of our results was possible given the retrospective nature of our study.

Conclusion

Despite our educational intervention, the inappropriate referrals remained high, and wait times increased. Other systemic interventions should be considered to attenuate the potential negative effects of eGFR reporting and ensure timely access for patients needing specialist consultation.

Electronic problem list documentation of chronic kidney disease and quality of care

Background

Chronic kidney disease (CKD) is increasingly common and under-recognized in primary care clinics, leading to low rates of stage-appropriate monitoring and treatment. Our objective was to determine whether electronic problem list documentation of CKD is associated with monitoring and treatment.

Methods

This is a cross-sectional observational study of patients with stage 3 or 4 CKD, defined as two past estimated glomerular filtration rates (eGFR) 15-60 mL/min/1.73 m² separated by 90 days and collected between 2007-2008. We examined the association of problem list documentation with: 1) serum eGFR monitoring test, 2) urine protein or albumin monitoring test, 3) an angiotensin converting enzyme inhibitor or angiotensin receptor blocker (ACE/ARB) prescription, 4) mean systolic blood pressure (BP), and 5) BP control.

Results

Out of 3,149 patients with stage 3 or 4 CKD, only 16% of patients had CKD documented on the problem list. After adjustment for eGFR, gender, and race/ethnicity and after clustering by physician, problem list documentation of CKD was associated with serum eGFR testing (97% with problem list documentation vs. 94% without problem list documentation, p = 0.02) and urine protein testing (47% with problem list documentation vs. 40% without problem list documentation, p = 0.04). After adjustment, problem list documentation was not associated with ACE/ARB prescription, mean systolic BP, or BP control.

Conclusions

Documentation of CKD on the electronic problem list is rare. Patients with CKD documentation have better stage-appropriate monitoring of the disease, but do not have higher rates of blood pressure treatment or better blood pressure control. Interventions aimed at increasing documentation of CKD on the problem list may improve stage-appropriate monitoring, but may not improve clinical outcomes.

Primary care physicians' familiarity, beliefs, and perceived barriers to practice guidelines in non-diabetic CKD: a survey study

BACKGROUND

Most non-dialysis dependent chronic kidney disease (CKD) patients are cared for by their primary care physicians (PCPs). Studies suggest many CKD patients receive suboptimal care. Recently, CKD clinical practice guidelines were updated with additional emphasis on albuminuria.

METHODS

We performed an internet-based, cross-sectional survey of active PCPs in the United States using the American Medical Association Physician Masterfile. We explored CKD guideline familiarity, self-reported practice behaviors, and attitudinal and external barriers to implementing guideline recommendations, including albuminuria testing.

RESULTS

Of 12,034 PCPs targeted, 848 opened a study email, 165 (19.5%) responded. Most respondents (88%) spent ≥50% of their time in clinical care. Respondents were generally in private practice (46%). Most PCPs (96%) felt that eGFR values were helpful. Approximately, 75% and 91% of PCPs reported testing for albuminuria in non-diabetic hypertensive patients with an eGFR > 60 ml/min/1.73 m2 and < 60 ml/min/1.73 m2, respectively. Barriers to albuminuria testing included a lack of effect on management, limited time, and the perceived absence of guidelines recommending testing. While PCPs expressed high levels of agreement with the definition of CKD, 30% were concerned with overdiagnosis in older adults with an eGFR in the CKD stage 3a range. Most PCPs felt that angiotensin converting enzyme inhibitor (ACEi)/ angiotensin II receptor blockers (ARBs) improved outcomes in CKD, though agreement was lower with severe vs. moderate albuminuria (78% vs. 85%, respectively, p = 0.03). Many PCPs (51%) reported being unfamiliar with CKD guidelines, but were receptive to systematic interventions to improve their CKD care.

CONCLUSIONS

PCPs generally agree with CKD clinical practice guidelines regarding CKD definition and albuminuria testing. However, future interventions are necessary to improve PCPs' familiarity with CKD guidelines, overcome barriers to albuminuria testing and, assist PCPs in targeting ACEi/ARBs to the patients most likely to benefit.

Challenges perceived by primary care providers to educating patients about chronic kidney disease

OBJECTIVE

To identify primary care providers' (PCPs) perceived barriers to educating patients about chronic kidney disease (CKD) during routine clinical visits.

METHODS

We conducted three focus groups of eighteen PCPs in Baltimore, Maryland (MD), USA. Focus groups began with the presentation of a hypothetical case of a patient with CKD, followed by open-ended questions to assess providers' perceived barriers to delivering education about CKD. Groups were audiotaped, transcribed and coded independently by two investigators who identified major themes.

RESULTS

PCPs reported on several patient, provider and system level barriers contributing to poor education about CKD in primary care that were both common and unique to barriers previously reported in educating patients regarding other chronic diseases.

CONCLUSIONS

Interventions designed to address barriers to CKD education identified by PCPs could improve the delivery of education about CKD in primary care settings.

Preventive and therapeutic effects of MG132 by activating Nrf2-ARE signaling pathway on oxidative stress-induced cardiovascular and renal injury

So far, cardiovascular and renal diseases have brought us not only huge economic burden but also serious society problems. Since effective therapeutic strategies are still limited, to find new methods for the prevention or therapy of these diseases is important. Oxidative stress has been found to play a critical role in the initiation and progression of cardiovascular and renal diseases. In addition, activation of nuclear-factor-E2-related-factor-2- (Nrf2-) antioxidant-responsive element (ARE) signaling pathway protects cells and tissues from oxidative damage. As a proteasomal inhibitor, MG132 was reported to activate Nrf2 expression and function, which was accompanied with significant preventive and/or therapeutic effect on cardiovascular and renal diseases under most conditions; therefore, MG132 seems to be a potentially effective drug to be used in the prevention of oxidative damage. In this paper, we will summarize the information available regarding the effect of MG132 on oxidative stress-induced cardiovascular and renal damage, especially through Nrf2-ARE signaling pathway.

Frailty and protein-energy wasting in elderly patients with end stage kidney disease

Older people constitute an increasingly greater proportion of patients with advanced CKD, including those patients undergoing maintenance dialysis treatment. Frailty is a biologic syndrome of decreased reserve and resistance to stressors that results from cumulative declines across multiple physiologic systems and causes vulnerability to adverse outcomes. Frailty is common in elderly CKD patients, and it may be associated with protein-energy wasting (PEW), sarcopenia, dynapenia, and other complications of CKD. Causes of frailty with or without PEW in the elderly with CKD can be classified into three categories: causes primarily caused by aging per se, advanced CKD per se, or a combination of both conditions. Frailty and PEW in elderly CKD patients are associated with impaired physical performance, disability, poorer quality of life, and reduced survival. Prevention and treatment of these conditions in the elderly CKD patients often require a multifaceted approach. Here, we examine the causes and consequences of these conditions and examine the interplay between frailty and PEW in elderly CKD patients.

Chronic kidney disease identification in a high-risk urban population: does automated eGFR reporting make a difference?

Whether automated estimated glomerular filtration rate (eGFR) reporting for patients is associated with improved provider recognition of chronic kidney disease (CKD), as measured by diagnostic coding of CKD in those with laboratory evidence of the disease, has not been explored in a poor, ethnically diverse, high-risk urban patient population. A retrospective cohort of 237 adult patients (≥ 20 years) with incident CKD (≥ 1 eGFR ≥ 60 ml/min/1.73 m(2), followed by ≥ 2 eGFRs <60 ml/min/1.73 m(2) ≥ 3 months apart)-pre- or post automated eGFR reporting-was identified within the San Francisco Department of Public Health Community Health Network (January 2005-July 2009). Patients were considered coded if any ICD-9-CM diagnostic codes for CKD (585.x), other kidney disease (580.x-581.x, 586.x), or diabetes (250.4) or hypertension (403.x, 404.x) CKD were present in the medical record within 6 months of incident CKD. Multivariable logistic regression was used to obtain adjusted odds ratios (ORs) for CKD coding. We found that, pre-eGFR reporting, 42.5 % of incident CKD patients were coded for CKD. Female gender, increased age, and non-Black race were associated with lower serum creatinine and lower prevalence of coding but comparable eGFR. Prevalence of coding was not statistically significantly higher overall (49.6 %, P = 0.27) or in subgroups after the institution of automated eGFR reporting. However, gaps in coding by age and gender were narrowed post-eGFR, even after adjustment for sociodemographic and clinical characteristics: 47.9 % of those <65 and 30.3 % of those ≥ 65 were coded pre-eGFR, compared to 49.0 % and 52.0 % post-eGFR (OR = 0.43 and 1.16); similarly, 53.2 % of males and 25.4 % of females were coded pre-eGFR compared to 52.8 % and 44.0 % post-eGFR (OR 0.28 vs. 0.64). Blacks were more likely to be coded in the post-eGFR period: OR = 1.08 and 1.43 (P (interaction) > 0.05). Automated eGFR reporting may help improve CKD recognition, but it is not sufficient to resolve under identification of CKD by safety net providers.

The primary care perspective on routine urine dipstick screening to identify patients with albuminuria

Proponents of routine urine dipstick screening to identify patients at risk for ESRD in the primary care setting have argued that urine dipsticks are inexpensive, low risk, acceptable to patients, and now, more accurate. Proponents believe that urine dipstick screening has the potential to improve outcomes for people with early disease and increase awareness of CKD. Most primary care physicians agree that populations who are at high risk for CKD should be tested and appropriately treated to decrease complications of ESRD. However, proponents of mass screening may not appreciate the challenges, limitations, and potential harms of screening. Urine dipstick testing does not meet all of the criteria for a good screening test. Screening the general population with urine dipsticks will generate many false positives--between 50% and 90% of positive tests--that will require follow-up, increase costs, and cause patient anxiety. Routine screening with urine dipsticks is not cost-effective on the order of $200,000 per quality-adjusted life year. Most importantly, there is little evidence that early identification of microalbuminuria in unselected patients influences outcomes of CKD. Without proof of effectiveness, overdiagnosis, a problem for even well established screening tests, is risked. Finally, no specialty society or preventive services group currently recommends general screening. Instead of screening, primary care physicians and nephrologists should work together to identify patients at high risk for ESRD and optimize management to improve outcomes for patients with CKD.

Estimated Glomerular Filtration Rate (eGFR): A Serum Creatinine-Based Test for the Detection of Chronic Kidney Disease and its Impact on Clinical Practice

Chronic kidney disease (CKD) is an important epidemic and public health problem that is associated with a significant risk for vascular disease and early cardiovascular mortality as well as progression of kidney disease. Currently it is classified into five stages based on the glomerular filtration rate (GFR) as recommended by many professional guidelines. Radiolabelled methods for measuring GFR are accurate but not practical and can be used only on a very limited scale while the traditional methods require timed urine collection with its drawback of inaccuracy, cumbersomeness and inconvenience for the patients. However, the development of formula- based calculation of estimated GFR (eGFR) has offered a very practical and easy approach for converting serum creatinine value into GFR result taking into consideration patient's age, sex, ethnicity and weight (depending on equation type). The commonly used equations include Cockraft and Gault (1976), Modification of Diet in Renal Disease (MDRD) (1999) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) (2009). It is the implementation of these equations particularly the MDRD that has raised the medical awareness in the diagnosis and management of CKD and its adoption by many guidelines in North America and Europe. The impact and pitfalls of each of these equations in the screening, diagnosis and management of patients with CKD are presented and discussed in this review.

Identification and management of chronic kidney disease complications by internal medicine residents: a national survey

Many patients with chronic kidney disease (CKD) receive care from primary care physicians. Identification and management of CKD complications in primary care is suboptimal. It is not known if current residency curriculum adequately prepares a future internist in this aspect of CKD care. We performed an online questionnaire survey of internal medicine residents in the United States to determine knowledge of CKD complications and their management. Four hundred seventy-nine residents completed the survey with postgraduate year (PGY) distribution 166 PGY1, 187 PGY2, and 126 PGY3. Most of the residents correctly recognized anemia (91%) and bone disease (82%) as complications at estimated glomerular filtration rate less than 60 mL/min/1.73 m; however, only half of the residents identified coronary artery disease (54%) as a CKD complication. For a patient with estimated glomerular filtration rate less than 60 mL/min/1.73 m, two thirds of the residents would workup for anemia (62%), whereas half of them would check for mineral and bone disorder (56%). With regard to anemia of CKD, less than half of the residents knew the CKD goal hemoglobin level of 11 to 12 g/dL (44%); most would supplement iron stores (86%), whereas fewer would consider nephrology referral (28%). For mineral and bone disorders, many residents would recommend dietary phosphorus restriction (68%) and check 25-hydroxyvitamin D (62%); fewer residents would start 1,25-dihydroxyvitamin D (40%) or refer to the nephrologist (45%). Residents chose to discontinue angiotensin-converting enzyme inhibitor for medication-related complication of greater than 50% decline in estimated glomerular filtration rate (68%) and potassium greater than 5.5 mEq/L (93%). Mean performance score improved with increasing PGY (PGY1 59.4% ± 17.6%, PGY2 63.6% ± 15.6%, and PGY3 66.2% ± 16.5%; P = 0.002). Our study identified specific gaps in knowledge of CKD complications and management among internal medicine residents. Educational efforts such as instruction on use of CKD clinical practice guidelines may help raise awareness of CKD complications, benefits of early intervention, and improve CKD management.

Why work together? Developing effective comanagement strategies for the care of patients with CKD

The ever-growing population of patients with CKD has prompted an increasing emphasis on earlier identification and proactive management by primary care providers. The provision of effective CKD care will necessitate a collegial relationship between the primary care providers and nephrologists exists. In this paper, barriers to the development of this working relationship, potential solutions within existing practice patterns, and newer ideas for effective communication will be explored.

Improving blood pressure control among adults with CKD and diabetes: provider-focused quality improvement using electronic health records

Current evidence demonstrates poor provider knowledge and compliance to clinical practice guidelines (CPGs) for CKD screening, blood pressure (BP) goals specific to people with diabetes mellitus (DM) and CKD, and underutilization or incorrect drug selection for antihypertensive therapy. This 12-week provider-focused quality improvement project sought to (1) increase primary care provider (PCP) adherence to CPG in the treatment and control of BP among adults with CKD and DM by using electronic health records (EHRs) and patient-level feedback (scorecards); (2) increase PCP delivery of basic CKD patient education by using EHR-based decision support; and (3) assess whether electronic decision support and scorecards changed provider behavior. The project included 46 PCPs, physicians, and nurse practitioners, in a statewide federally qualified health center that operates 12 comprehensive primary care sites in Connecticut. There were 6781 DM visits, among 3137 unique, racially diverse patients. There was a statistically significant increase in CKD screening, diagnosis, and use of angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker. There was a statistically, but not clinically, significant increase in CKD basic education and ancillary service provider use when the provider was aware of the diagnosis or used EHR enhancements. EHR decision support and real-time provider feedback are necessary but not sufficient to improve uptake of CPG and to change PCP behavior.

Prevalence of Diagnosis and Staging of Chronic Kidney Disease by Primary Care Providers in a Rural State

Context: The Kidney Disease Outcomes and Quality Initiative guidelines are the most widely disseminated guidelines regarding the clinical evaluation and management of chronic kidney disease (CKD). Purpose: Assess the prevalence of diagnosis and staging of CKD by primary care providers (PCPs). Methods: For the purpose of this assessment, stage 3 CKD was defined as an estimated glomerular filtration rate (eGFR) between 30 and 59 mL/min/1.73 m2 for at least 3 months. Eligible individuals were 1447 white, nondiabetic patients 40-74 years of age. Results: Information on a random sample of 110 patients was analyzed. Chronic kidney disease was reported in 22% of the patients, whereas only 7% of patients had both CKD and stage 3 reported in their medical record. PCPs were significantly more likely to record CKD in male than in female patients (79% vs 34%; P < .001). Patients who had CKD recorded were significantly more likely to be referred to a nephrologist (46% vs 3%; P < .001). Even among patients who had a diagnosis of coronary artery disease, were older, or had lower eGFR, a diagnosis of CKD was less likely to be recorded. Only 22% had their serum phosphorus, 12% their parathyroid hormone, and 64% a urinalysis recorded. Conclusions: This study found that the prevalence of recording CKD and staging by PCPs was low. Primary care providers were more likely to record CKD in male than in female patients. Finally, testing for bone disease is underperformed. There is a need to identify mechanisms to improve evaluation and management of CKD by PCPs.

Primary care management of chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) causes substantial morbidity and mortality; however, there are limited data to comprehensively assess quality of care in this area.

OBJECTIVE

To assess quality of care for CKD according to patient risk and identify correlates of improved care delivery.

DESIGN

Retrospective cohort.

SETTING

Fifteen health centers within a multi-site group practice in eastern Massachusetts.

PARTICIPANTS

166 primary care physicians caring for 11,774 patients with stages 3 or 4 CKD defined as two estimated glomerular filtration rates (eGFR) between 15 and 60.

MAIN MEASURES

Two measures of kidney disease monitoring, five measures of cardiovascular disease management, four measures of metabolic bone disease and anemia management, and one measure of drug safety were extracted from the electronic health record. Primary care recognition of CKD was assessed as a problem list diagnosis, and nephrology co-management was assessed as at least one visit with a nephrologist in the prior 12 months.

KEY RESULTS

Overall, 46% of patients were high risk for death based on the presence of diabetes, proteinuria, or an eGFR <45. Seventy percent of patients lacked annual urine protein testing, 46% had a blood pressure ≥130/80 mmHg and 25% were not receiving appropriate angiotensin blockade. Appropriate screening for anemia was common (76%), while screening rates for metabolic bone disease were low. Use of potentially harmful drugs was common (26%). Primary care physician recognition and nephrology co-management were both associated with improved quality of care, though rates of both were low (24% and 10%, respectively).

CONCLUSIONS

Significant deficiencies in the quality of CKD care exist. Opportunities for improvement include increasing physician recognition of CKD and improving collaborative care with nephrology.

Management of high blood pressure in Blacks: an update of the International Society on Hypertension in Blacks consensus statement

Since the first International Society on Hypertension in Blacks consensus statement on the "Management of High Blood Pressure in African American" in 2003, data from additional clinical trials have become available. We reviewed hypertension and cardiovascular disease prevention and treatment guidelines, pharmacological hypertension clinical end point trials, and blood pressure-lowering trials in blacks. Selected trials without significant black representation were considered. In this update, blacks with hypertension are divided into 2 risk strata, primary prevention, where elevated blood pressure without target organ damage, preclinical cardiovascular disease, or overt cardiovascular disease for whom blood pressure consistently <135/85 mm Hg is recommended, and secondary prevention, where elevated blood pressure with target organ damage, preclinical cardiovascular disease, and/or a history of cardiovascular disease, for whom blood pressure consistently <130/80 mm Hg is recommended. If blood pressure is ≤10 mm Hg above target levels, monotherapy with a diuretic or calcium channel blocker is preferred. When blood pressure is >15/10 mm Hg above target, 2-drug therapy is recommended, with either a calcium channel blocker plus a renin-angiotensin system blocker or, alternatively, in edematous and/or volume-overload states, with a thiazide diuretic plus a renin-angiotensin system blocker. Effective multidrug therapeutic combinations through 4 drugs are described. Comprehensive lifestyle modifications should be initiated in blacks when blood pressure is ≥115/75 mm Hg. The updated International Society on Hypertension in Blacks consensus statement on hypertension management in blacks lowers the minimum target blood pressure level for the lowest-risk blacks, emphasizes effective multidrug regimens, and de-emphasizes monotherapy.

Diagnosis and management of mineral metabolism in CKD

BACKGROUND

Chronic kidney disease (CKD) affects over 26 million Americans and is frequently complicated early in its course by disordered mineral metabolism and metabolic bone disease. Since CKD-related bone loss is often indistinguishable from osteoporosis by standard bone densitometry, many CKD patients may be inappropriately treated with bisphosphonates rather than CKD-specific therapies.

OBJECTIVE

To determine the prevalence of appropriate evaluation, diagnosis and management of metabolic bone disease among individuals with pre-dialysis CKD.

DESIGN AND PARTICIPANTS

Retrospective cohort study using electronic medical records of 69,215 ambulatory patients seen in the primary care clinics of an academic medical center.

MEASUREMENTS

Prevalence of CKD stages 3-4, frequency of diagnostic testing and treatment of metabolic bone disease.

MAIN RESULTS

Based on current diagnostic criteria and consistent with national data, CKD was present in 12% of the population. Bisphosphonates were used in 7.2% of patients, 20% of whom met criteria for CKD. Fewer than half of CKD patients underwent testing for parathyroid hormone (PTH) or 25-hydroxyvitamin D (25D) levels. Among those tested, vitamin D deficiency (25D <30 ng/ml) and secondary hyperparathyroidism (PTH >60 pg/ml) were present in 65% and 55%, respectively. Among patients with CKD, bisphosphonate use was nearly seven times as frequent as therapy with active vitamin D (12% vs. 1.7%, p < 0.0001), a primary treatment for CKD-associated metabolic bone disease.

CONCLUSIONS

Disordered mineral metabolism in CKD is common, under-diagnosed and under-treated. As a result, bisphosphonates may be prescribed inappropriately in patients with CKD.

The role of primary care in the management of the chronic kidney disease population

With the recognition of the high prevalence of CKD and its associated morbidity and mortality, increasing attention has focused on how to optimally provide care to this population. An immediate concern is that the sheer size of the population with early-stage CKD will overwhelm the capacity of the current nephrology workforce. Thus, the burden of care for most CKD patients will likely have to fall on primary care physicians (PCPs). This article reviews the issues surrounding the role of primary care in the management of the CKD population. Topics covered include specific roles that PCPs can play in the care of CKD patients, barriers and challenges to PCP involvement, and a discussion of strategies to improve the care provided to CKD patients by PCPs.

Awareness of chronic kidney disease among patients and providers

Earlier recognition of chronic kidney disease (CKD) could slow progression, prevent complications, and reduce cardiovascular-related outcomes. However, current estimates of CKD awareness indicate that both patient- and provider-level awareness remain unacceptably low. Many of the factors that are possibly associated with CKD awareness, which could help guide implementation of awareness efforts, have yet to be fully examined. Also, little is known regarding whether increased patient or provider awareness improves clinical outcomes, or whether there are possible negative consequences of awareness for CKD patients. Further research is necessary to continue to design and refine awareness campaigns aimed at both patients and providers, but there is an immediate need for dissemination of basic CKD information, given both the high prevalence of CKD and its risk factors and the low estimated awareness of CKD.

Perceived susceptibility to chronic kidney disease among high-risk patients seen in primary care practices

BACKGROUND

Patients' views of their risk for the development or progression of chronic kidney disease (CKD) are poorly characterized.

OBJECTIVE

To assess perceived risk and concern regarding CKD development or progression among high-risk patients seen in primary care, identify predictors of perceptions, and correlate perceptions with adherence to high blood pressure management.

DESIGN AND PARTICIPANTS

Cross-sectional study of 195 patients enrolled in a randomized controlled trial on hypertension management in 40 Maryland primary care practices.

MEASUREMENTS

We assessed independent predictors (sociodemographics, health literacy, clinical presence of CKD, co-morbid conditions, and health behaviors) of perceived susceptibility (assessed via questionnaire) and adherence (assessed via Hill-Bone blood pressure adherence scale) in multivariable analyses.

MAIN RESULTS

In this hypertensive majority African American (63%) population, many participants had uncontrolled blood pressure (44%) or diabetes (42%). Few (20%) felt "very likely" to develop CKD and one third (33%) were "very concerned" about developing CKD. Participants who were female and had low health literacy had lower perceived susceptibility to CKD compared to males and those with higher health literacy. Race and diabetes were also associated with perceived susceptibility. Greater perceived susceptibility was associated with poorer blood pressure management adherence scores.

CONCLUSIONS

Many high-risk patients have low perceived susceptibility to CKD. Poor blood pressure therapy adherence scores among those with greatest perceived susceptibility suggest fatalistic attitudes about CKD. If our findings are confirmed in larger studies, interventions targeting patient perceptions of CKD risk and other attitudes associated with these perceptions could impact adherence to therapies and health outcomes.

Estimated GFR reporting is not sufficient to allow detection of chronic kidney disease in an Italian regional hospital

Background

Chronic kidney disease (CKD) is an emerging worldwide problem. The lack of attention paid to kidney disease is well known and has been described in previous publications. However, little is known about the magnitude of the problem in highly specialized hospitals where serum creatinine values are used to estimate GFR values.

Methods

We performed a cross-sectional evaluation of hospitalized adult patients who were admitted to the medical or surgical department of Santa Maria della Misericordia Hospital in 2007. Information regarding admissions was derived from a database. Our goal was to assess the prevalence of CKD (defined as an estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m²) and detection of CKD using diagnostic codes (Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]). To reduce the impact of acute renal failure on the study, the last eGFR obtained during hospitalization was the value used for analysis, and intensive care and nephrology unit admissions were excluded. We also excluded patients who had ICD-9-CM codes for renal replacement therapy, acute renal failure, and contrast administration listed as discharge diagnoses.

Results

Of the 18,412 patients included in the study, 4,748 (25.8%) had reduced eGFRs, falling into the category of Kidney Disease Outcomes Quality Initiative (KDOQI) stage 3 (or higher) CKD. However, the diagnosis of CKD was only reported in 19% of these patients (904/4,748). It is therefore evident that there was a "gray area" corresponding to stage 3 CKD (eGFR 30-59 ml/min), in which most CKD diagnoses are missed. The ICD-9 code sensitivity for detecting CKD was significantly higher in patients with diabetes, hypertension, and cardiovascular disease (26.8%, 22.2%, and 23.7%, respectively) than in subjects without diabetes, hypertension, or cardiovascular disease (p < 0.001), but these values are low when the widely described relationship between such comorbidities and CKD is considered.

Conclusion

Although CKD was common in this patient population at a large inpatient regional hospital, the low rates of CKD detection emphasize the primary role nephrologists must play in continued medical education, and the need for ongoing efforts to train physicians (particularly primary care providers) regarding eGFR interpretation and systematic screening for CKD in high-risk patients (i.e., the elderly, diabetics, hypertensives, and patients with CV disease).

Referral patterns to renal services: what has changed in the past 4 years?

BACKGROUND

Awareness of chronic kidney disease (CKD) has been prompted by the publication of several large epidemiological studies since 2002. This has led to various initiatives for the early identification and management of CKD, including the introduction of automated glomerular filtration rate (GFR) reporting and renal indicators in the primary care quality and outcomes framework (QOF) since April 2006. These initiatives were intended to promote identification of CKD and have had an impact on referral patterns to renal services. The aim of this study was to understand the nature of this impact in a catchment population of 1.2 million people.

METHODS

Data were collected and recorded from all written referrals from primary care between 1 April 2004 and 31 March 2008. Referral patterns for each postcode sector were mapped using Microsoft MapPoint 2004. The effect of chance on referral patterns was modelled by using small area analysis techniques. The association between the CKD prevalence reported from QOF data and the estimated CKD prevalence was examined at post-code district level.

RESULTS

There were 1461 referrals in 2 years prior to the introduction of the initiatives and 2890 referrals in the 2 years post-introduction. The main reason for referral in both groups was impaired renal function or previously established renal disease. Reported comorbidity was similar between the groups. Mapping showed that there was wide heterogeneity in referral behaviour in the first 2 years of the study, which was less in the second period. Small area analysis suggested that the variation that led to the extremal quotients observed in both of the study periods was not due to random variation in referral pattern alone. There was no correlation between the reported CKD prevalence and the referral rates.

CONCLUSION

Referral patterns have changed between 1 April 2004 and 31 March 2008. The main findings were an increase in referral rate and in the age at referral without a significant change in reported comorbidity of the people referred. The main increase in referral rates was seen in more advanced CKD suggesting more targeted referral of patients with CKD to renal services.

Blood pressure control among persons without and with chronic kidney disease: US trends and risk factors 1999-2006

Recent guidelines recommending more aggressive blood pressure control in patients with chronic kidney disease have unknown impact. We assessed trends in and predictors of blood pressure control in 8829 adult National Health and Nutrition Examination Survey 1999-2006 participants with hypertension (self-report, measured blood pressure, or use of antihypertensive medications), without (n=7178) and with (n=1651) chronic kidney disease. Uncontrolled blood pressure was defined as follows: general definition, systolic blood pressure > or =140 mm Hg and diastolic blood pressure > or =90 mm Hg, and disease-specific definition, systolic blood pressure > or =130 mm Hg and diastolic blood pressure > or =85 mm Hg (1999-2002) and systolic blood pressure > or =130 mm Hg and diastolic blood pressure > or =80 mm Hg (2003-2006) for those with chronic kidney disease (estimated glomerular filtration rate: <60 mL/min per 1.73 m(2)) or diabetes mellitus (self-report). Proportions with uncontrolled blood pressure in 1999-2006 were greater in those with chronic kidney disease versus those without chronic kidney disease (51.5% versus 48.7% [general definition: P=0.122] and 68.8% versus 51.7% [disease-specific definition: P<0.001]). In those with chronic kidney disease, there were significant decreases in uncontrolled blood pressure over time (55.9% to 47.8% [general definition: P=0.011]). With adjustment for demographic, socioeconomic, and clinical variables, older age (P<0.001) and lack of antihypertensive treatment (P<0.001) were associated with uncontrolled blood pressure, regardless of chronic kidney disease status; nonwhite race (P=0.002) was associated in those without chronic kidney disease, whereas female sex (P=0.030) was associated in those with chronic kidney disease. Multiple medications (P<0.001) and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (P=0.001) were associated with less uncontrolled blood pressure. Although some improvement has occurred over time, uncontrolled blood pressure remains highly prevalent, especially in subjects with chronic kidney disease and in nonwhites, older persons, and women. Therapy appears suboptimal.

Clinical testing patterns and cost implications of variation in the evaluation of CKD among US physicians

BACKGROUND

Clinical practice guidelines were established to improve the diagnosis and management of chronic kidney disease (CKD), but the extent, determinants, and cost implications of guideline adherence and variation in adherence have not been evaluated.

STUDY DESIGN

Cross-sectional survey.

SETTINGS & PARTICIPANTS

The questionnaire was sent (on paper or through the internet) to a nationally representative sample of 1,200 US primary care physicians and nephrologists.

PREDICTOR

Provider and patient characteristics.

OUTCOMES & MEASUREMENTS

Guideline adherence was assessed as present if physicians recommended at least 5 of 6 clinical tests prescribed by the National Kidney Foundation's Kidney Disease Outcomes and Quality Initiative guidelines for a hypothetical patient with newly identified CKD. We also assessed patterns and costs of additional nonrecommended tests for the initial clinical evaluation of CKD.

RESULTS

Of the 301 (86 family medicine, 89 internal medicine, and 126 nephrology) eligible physicians who responded to the survey (response rate, 32%), most practiced longer than 10 years (54%), were in nonacademic practices (76%), spent greater than 80% of their time performing clinical duties (77%), and correctly estimated kidney function (73%). Overall, 35% of participants were guideline adherent. Compared with nephrologists, internal medicine and family physicians had lower odds of adherence for all recommended testing (odds ratio, 0.6; 95% confidence interval, 0.3 to 1.1; and odds ratio, 0.3; 95% confidence interval, 0.1 to 0.6, respectively). Participants practicing longer than 10 years had lower odds of ordering all recommended testing compared with participants practicing fewer than 10 years (odds ratio, 0.5; 95% confidence interval, 0.3 to 0.9). Eighty-five percent of participants recommended additional tests, which resulted in a 23% increased total per-patient cost of the clinical evaluation.

LIMITATIONS

Recommendations for a hypothetical case scenario may differ from those of actual patients.

CONCLUSIONS

Adherence to recommended clinical testing for the diagnosis and management of CKD was poor, and additional testing was associated with substantially increased cost of the clinical evaluation. Improved clarity, dissemination, and uptake of existing guidelines are needed to improve quality and decrease costs of care for patients with CKD.

Treatment center and geographic variability in pre-ESRD care associate with increased mortality

Late referral of patients with chronic kidney disease is associated with increased morbidity and mortality, but the contribution of center-to-center and geographic variability of pre-ESRD nephrology care to mortality of patients with ESRD is unknown. We evaluated the pre-ESRD care of > 30,000 incident hemodialysis patients, 5088 (17.8%) of whom died during follow-up (median 365 d). Approximately half (51.3%) of incident patients had received at least 6 mo of pre-ESRD nephrology care, as reported by attending physicians. Pre-ESRD nephrology care was independently associated with survival (odds ratio 1.54; 95% confidence interval 1.45 to 1.64). There was substantial center-to-center variability in pre-ESRD care, which was associated with increased facility-specific death rates. As the proportion of patients who were in a treatment center and receiving pre-ESRD nephrology care increased from lowest to highest quintile, the mortality rate decreased from 19.6 to 16.1% (P = 0.0031). In addition, treatment centers in the lowest quintile of pre-ESRD care were clustered geographically. In conclusion, pre-ESRD nephrology care is highly variable among treatment centers and geographic regions. Targeting these disparities could have substantial clinical impact, because the absence of > or = 6 mo of pre-ESRD care by a nephrologist is associated with a higher risk for death.

Individuals with a family history of ESRD are a high-risk population for CKD: implications for targeted surveillance and intervention activities

Activities intended to improve the detection, treatment, and control of chronic kidney disease (CKD) should be incorporated into existing health care systems and targeted to high-risk populations to avoid redundancy and waste of resources. One high-risk population consists of first- or second-degree family members of patients with end-stage renal disease (ESRD), who are 2 to 3 times as likely to have incident ESRD, have high rates of impaired kidney function and undetected and uncontrolled high blood pressure, and are more likely to be obese. These individuals usually are unaware of their underlying CKD and may discount their own risk of ESRD. The ESRD Network 6 Family History Project shows that the ESRD Networks, which constitute a national CKD surveillance system for patients with stage 5 CKD, may be an existing resource that can be used to identify relatives of incident patients with ESRD and provide these families with information about CKD. Nationally available resources have been developed by the National Kidney Disease Education Program for use with these at-risk families. Individuals interested in population-based CKD control activities should be aware of and use these resources.

Population-based screening for CKD

Organizations both in the United States and globally have advocated for screening for chronic kidney disease with a urine test for proteinuria followed by subsequent testing with creatinine-based estimated glomerular filtration rate determinations. Screening for a disease, such as chronic kidney disease, can have value, but a decision to screen is not a trivial decision. Criteria must be met to balance the aggregate benefits with the risks and costs of a screening test. We discuss how screening for chronic kidney disease meets many of these criteria, but also how the populations to which it is applied must be targeted and the strategies for testing must be clearly defined.

Patient awareness of chronic kidney disease: trends and predictors

BACKGROUND

The impact of recent guidelines for early detection and prevention of chronic kidney disease (CKD) on patient awareness of disease and factors that might be associated with awareness have not been well described.

METHODS

Awareness rates were assessed in 2992 adults (age, > or =20 years) with CKD stages 1 to 4 from a nationally representative, cross-sectional survey (National Health and Nutrition Examination Survey 1999-2004). Awareness of CKD was defined by an answer of yes to "Have you ever been told you have weak or failing kidneys?" Potential predictors of awareness included demographics, access to care, and clinical and lifestyle factors, which were assessed by standardized interviewer-administered questionnaires and physical examinations. We examined independent associations of patient characteristics with awareness in those with CKD stage 3 (n = 1314) over 6 years using multivariable logistic regression.

RESULTS

Awareness improved over time in those with CKD stage 3 only (4.7% [95% confidence interval {CI}, 2.6%-8.5%], 8.9% [95% CI, 7.1%-11.2%], and 9.2% [95% CI, 6.1%-13.8%] for 1999-2000, 2001-2002, and 2003-2004, respectively; P = .04, adjusted for age, sex, and race). Having proteinuria (odds ratio, 3.04 [95% CI, 1.62-5.70]), diabetes (OR, 2.19 [95% CI, 1.03-4.64]), and hypertension (OR, 2.92 [95% CI, 1.57-5.42]) and being male (OR, 2.06 [95% CI, 1.15-3.69]) were all statistically significantly associated with greater awareness among persons with CKD stage 3 after adjustment. Chronic kidney disease awareness increased almost 2-fold for those with CKD stage 3 over recent years but remains low. Persons with risk factors for CKD (proteinuria, diabetes, hypertension, and male sex) were more likely to be aware of their stage 3 disease.

CONCLUSION

Renewed and innovative efforts should be made to increase CKD awareness among patients and health care providers.

Recognition and management of chronic kidney disease in an elderly ambulatory population

BACKGROUND

Chronic kidney disease (CKD) is a growing problem among the elderly. Early detection is considered essential to ensure proper treatment and to avoid drug toxicity, but detection is challenging because elderly patients with CKD often have normal serum creatinine levels. We hypothesized that most cases of CKD in the elderly would go undetected, resulting in inappropriate prescribing.

OBJECTIVE

To determine whether recognition of CKD is associated with more appropriate treatment

DESIGN

Retrospective chart review

PARTICIPANTS

All patients aged >/=65 years with a measured serum creatinine in the past 3 years at 2 inner city academic health centers.

MEASUREMENTS

Estimated glomerular filtration rate (eGFR) calculated using the Modified Diet in Renal Disease equation, and for patients with eGFR < 60, documentation of CKD by the provider, diagnostic testing, nephrology referral and prescription of appropriate or contraindicated medications.

RESULTS

Of 814 patients with sufficient information to estimate eGFR, 192 (33%) had moderate (eGFR < 60 mL/min) and 5% had severe (eGFR < 30 mL/min) CKD. Providers identified 38% of moderate and 87% of severe CKD. Compared to patients without recognized CKD, recognized patients were more likely to receive an ACE/ARB (80% vs 61%, p = .001), a nephrology referral (58% vs 2%, p < .0001), or urine testing (75% vs 47%, p < .0001), and less likely to receive contraindicated medications (26% vs 40%, p = .013).

CONCLUSIONS

Physicians frequently fail to diagnose CKD in the elderly, leading to inappropriate treatment. Efforts should focus on helping physicians better identify patients with low GFR.

Let's get serious about racial and ethnic disparities

Racial and ethnic disparities in health and health care have been documented for over two decades in kidney disease, in a variety of other conditions, across settings, and for different medical and surgical interventions. We now have government reports that track progress on reducing racial disparities, but the pace of progress has been disheartening. The reasons for some of these disparities are known and include biologic, socioeconomic, cultural, and environmental factors as well as system, patient, and provider factors that affect access and quality of medical services. For other disparities, they remain an enigma. Solutions have been slow incoming in large part because we have not held ourselves, and others, accountable for better results. It is time to get serious about equitable health care for all of us.

Detection and awareness of moderate to advanced CKD by primary care practitioners: a cross-sectional study from Italy

BACKGROUND

Chronic kidney disease (CKD) is a strong independent predictor of cardiovascular disease. Although general practitioners (GPs) represent the first line for identification of these high-risk patients, their diagnostic approach to CKD is ill defined.

STUDY DESIGN

Cross-sectional evaluation of database of Italian GPs.

SETTING & PARTICIPANTS

Representative sample of adult Italian population regularly followed up by GPs in 2003.

OUTCOMES

Frequency of serum creatinine testing, prevalence of CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m(2)), awareness of CKD assessed from use of diagnostic codes (Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) for CKD, and referral to nephrologists.

RESULTS

Of 451,548 individuals in the entire practice population, only 77,630 (17.2%) underwent serum creatinine testing. Female sex (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.06 to 1.12), advanced age (OR, 2.70; 95% CI, 2.63 to 2.78), diabetes (OR, 1.31; 95% CI, 1.20 to 1.42), hypertension (OR, 1.10; 95% CI, 1.02 to 1.19), autoimmune diseases (OR, 1.42; 95% CI, 1.11 to 1.82), and recurrent urinary tract infections (OR, 1.63; 95% CI, 1.10 to 2.42) were all associated with serum creatinine testing. Conversely, use of either nonsteroidal anti-inflammatory drugs (OR, 1.03; 95% CI, 0.89 to 1.21) or aminoglycosides or contrast media (OR, 0.78; 95% CI, 0.54 to 1.14) was not associated with serum creatinine testing. In the subgroup with serum creatinine data, the age-adjusted prevalence of CKD was 9.33% (11.93% in women, 6.49% in men). However, in patients with eGFR less than 60 mL/min/1.73 m(2), serum creatinine values were apparently normal (<1.2 mg/dL in women, <1.4 mg/dL in men) in 54%, and GPs used ICD-9-CM codes for CKD in only 15.2%. Referral to nephrologists ranged from 4.9% for patients with eGFR of 59 to 30 mL/min/1.73 m(2) to 55.7% for those with eGFR less than 30 mL/min/1.73 m(2).

LIMITATIONS

The prevalence of decreased kidney function may be overestimated because of the more frequent serum creatinine testing in sicker individuals and lack of creatinine calibration.

CONCLUSIONS

In primary care, CKD stages 3 to 5 are frequent, but its awareness is scarce because of limited rates of serum creatinine testing and difficulty recognizing decreased eGFR in the absence of increased serum creatinine testing.

Attitudes and behaviors of African Americans regarding early detection of kidney disease

BACKGROUND

Chronic kidney disease (CKD) is an African American public health crisis. To inform interventions, the National Kidney Disease Education Program surveyed African Americans about their attitudes and behaviors regarding early detection of kidney disease and screening.

STUDY DESIGN

Cross-sectional study.

SETTING & PARTICIPANTS

2,017 African Americans from 7 states (Georgia, Maryland, Ohio, Mississippi, Louisiana, Missouri, and Tennessee) selected by using a random-digit dialing telephone survey (response rate, 42.4%).

PREDICTORS

Demographic, risk, knowledge, and behavior variables.

OUTCOMES & MEASUREMENTS

Perception of CKD as a top health concern, perceived risk of getting kidney disease, and accurate knowledge about CKD and its prevention.

RESULTS

Only 23.5% of African Americans were screened for kidney disease in the last year. Although almost half (43.7%) of African Americans had a CKD risk factor, only 2.8% reported that CKD was a top health concern. Almost half knew the correct definition of kidney disease (48.6%), but few knew a test to diagnose CKD (23.7%) or that African Americans were at greater risk of developing CKD (18.1%). African Americans who had diabetes (odds ratio [OR], 3.22; 95% confidence interval [CI], 2.17 to 4.76), hypertension (OR, 1.78; 95% CI, 1.28 to 2.44), at least a bachelor's degree (OR, 1.77; 95% CI, 1.17 to 2.66), who had spoken with a medical professional (OR, 1.85; 95% CI, 1.19 to 2.85) or their family (OR, 1.61; 95% CI, 1.11 to 2.38) about kidney disease, who knew that a family history of kidney disease is a risk factor (OR, 2.32; 95% CI, 1.08 to 5.0), and who had been tested for CKD in the last year (OR, 1.45; 95% CI, 1.03 to 2.0) were more likely to correctly perceive themselves at increased risk.

LIMITATIONS

Respondents were primarily African American women from urban areas.

CONCLUSIONS

Most African Americans have poor knowledge about CKD, do not perceive it as an important health problem, and are not getting screened. To increase early detection of kidney disease through screenings, educational efforts linking kidney disease prevention to other diseases that are health priorities for African Americans are necessary.

Older adults and chronic kidney disease decision making by primary care physicians: a scholarly review and research agenda

BACKGROUND

Chronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults.

OBJECTIVE

This scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD.

RESULTS

While age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD.

CONCLUSIONS

More information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.