The role of comprehensive renal clinic in chronic kidney disease stabilization and management: The Northwestern experience

Therapeutic modalities in diabetic nephropathy: standard and emerging approaches

Diabetes mellitus is the leading cause of end stage renal disease and is responsible for more than 40% of all cases in the United States. Current therapy directed at delaying the progression of diabetic nephropathy includes intensive glycemic and optimal blood pressure control, proteinuria/albuminuria reduction, interruption of the renin-angiotensin-aldosterone system through the use of angiotensin converting enzyme inhibitors and angiotensin type-1 receptor blockers, along with dietary modification and cholesterol lowering agents. However, the renal protection provided by these therapeutic modalities is incomplete. More effective approaches are urgently needed. This review highlights the available standard therapeutic approaches to manage progressive diabetic nephropathy, including markers for early diagnosis of diabetic nephropathy. Furthermore, we will discuss emerging strategies such as PPAR-gamma agonists, Endothelin blockers, vitamin D activation and inflammation modulation. Finally, we will summarize the recommendations of these interventions for the primary care practitioner.

Characterizing pre-dialysis care in the era of eGFR reporting: a cohort study

Background

Chronic kidney disease (CKD) is a common disorder associated with increased morbidity and mortality. Primary care physicians (PCPs) care for the majority of pre-dialysis CKD patients; however, PCPs often do not recognize the presence of CKD based on serum creatinine levels. Prior studies suggest that PCPs and nephrologists deliver suboptimal CKD care. One strategy to improve disease awareness and treatment is estimated glomerular filtration rate (eGFR) reporting. We examined PCP and nephrologist CKD practices before and after routine eGFR reporting.

Methods

We conducted a retrospective cohort study of patients with CKD 3b-4 (eGFR < 45) seen at a university-based, outpatient primary care clinic. Using a chi-square or Fisher's exact test, we compared co-management rates, renal protective strategies, CKD documentation, and laboratory processes of care in 274 patients and 266 patients seen in a 6-month period prior to and following eGFR implementation, respectively.

Results

CKD co-management increased from 22.6% pre-eGFR to 48.5% post-eGFR (P < 0.0001). eGFR reporting did not improve angiotensin converting enzyme inhibitor or angiotensin receptor blocker use or quantitative urinary testing. However, non-steroidal anti-inflammatory drug avoidance (pre-eGFR 81.8% vs. post- eGFR 90.6%, P = 0.003) and phosphorus and parathyroid hormone testing improved (pre-eGFR vs. post-eGFR: 32.5% vs. 51.5%, P < 0.0001; 12.4% vs. 36.1%, P < 0.0001 respectively).

Conclusions

A marked increase in CKD co-management was observed following eGFR implementation. Although some improvements in processes of care were noted, this did not include angiotensin converting enzyme inhibitor or angiotensin receptor blocker use. Overall care remained suboptimal despite eGFR reporting; further strategies are needed to improve PCP and nephrologist CKD care.

Multidisciplinary team care may slow the rate of decline in renal function

BACKGROUND AND OBJECTIVES

A multidisciplinary team (MDT) approach to chronic kidney disease (CKD) may help optimize care of CKD and comorbidities. We implemented an MDT quality improvement project for persons with stage 3 CKD and comorbid diabetes and/or hypertension. Our objective was to decrease the rate of decline of GFR.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used a 4-year historical cohort to compare 1769 persons referred for usual nephrology care versus 233 referred for MDT care within an integrated, not-for-profit Health Maintenance Organization (HMO). Usual care consisted of referral to an outside nephrologist. The MDT consisted of an HMO-based nephrologist, pharmacy specialist, diabetes educator, dietitian, social worker, and nephrology nurse. Both groups received usual primary care. The primary outcome was rate of decline of GFR. Secondary outcomes were LDL, hemoglobin A1c, and BP.

RESULTS

In multivariate repeated-measures analyses, MDT care was associated with a mean annual decline in GFR of 1.2 versus 2.5 ml/min per 1.73 m(2) for usual care. In stratified analyses, the significant difference in GFR decline persisted only in those who completed their referrals. There were no differences in the secondary outcomes between groups.

CONCLUSIONS

In this integrated care setting, MDT care resulted in a slower decline in GFR than usual care. This occurred despite a lack of significant differences for secondary disease-specific measures, suggesting that other differences in the MDT population or care process accounted for the slower decline in GFR in the MDT group.

Impact of a chronic kidney disease clinic on preemptive kidney transplantation and transplant wait times

BACKGROUND

Despite the known benefits of preemptive kidney transplantation, its rate of use remains low.

OBJECTIVE

To determine whether focused, comprehensive education provided at a clinic for patients with chronic kidney disease would improve the rate of preemptive transplantation and transplant wait times.

METHODS

A retrospective cohort study design was used. The rate of preemptive transplantation and transplant wait times were compared between patients with end-stage renal disease who had been followed in a chronic kidney disease clinic for more than 3 months and patients with end-stage kidney disease who had not been followed for chronic kidney disease care during the same period.

RESULTS

More African Americans than others had initiated dialysis without having had previous care for chronic kidney disease. The rate of preemptive transplantation was 24% for patients followed in the clinic. For those patients without living donor options, mean transplant referral time was significantly different between patients followed at the clinic and patients who were not: 234 (SD, 392) days before dialysis was started versus 161 (SD, 525) days after dialysis was started (P = .01).

CONCLUSION

A chronic kidney disease clinic can influence rates of preemptive kidney transplantation and transplantation referral times.

Impact of a Chronic Kidney Disease Clinic on Preemptive Kidney Transplantation and Transplant Wait Times

Background

Despite the known benefits of preemptive kidney transplantation, its rate of use remains low.

Objective

To determine whether focused, comprehensive education provided at a clinic for patients with chronic kidney disease would improve the rate of preemptive transplantation and transplant wait times.

Methods

A retrospective cohort study design was used. The rate of preemptive transplantation and transplant wait times were compared between patients with end-stage renal disease who had been followed in a chronic kidney disease clinic for more than 3 months and patients with end-stage kidney disease who had not been followed for chronic kidney disease care during the same period.

Results

More African Americans than others had initiated dialysis without having had previous care for chronic kidney disease. The rate of preemptive transplantation was 24% for patients followed in the clinic. For those patients without living donor options, mean transplant referral time was significantly different between patients followed at the clinic and patients who were not: 234 (SD, 392) days before dialysis was started versus 161 (SD, 525) days after dialysis was started ( P= .01).

Conclusion

A chronic kidney disease clinic can influence rates of preemptive kidney transplantation and transplantation referral times.

Effectiveness of a multidisciplinary clinic in managing children with chronic kidney disease

BACKGROUND AND OBJECTIVES

Long-term outcome of patients with chronic kidney disease (CKD) correlates with adequacy of predialysis care. This is best provided in a multidisciplinary clinic that integrates the services of a nephrologist with other staff. There is limited data about such clinics in children. The Children's Hospital of Michigan established a Chronic Renal Insufficiency (CRI) clinic in 2002 to provide comprehensive care to children with CKD. These children receive care from a nephrologist, nurse clinician, transplant coordinator, dietician, social worker, and psychologist. The objective of the study was to compare outcome variables between patients from the CRI clinic and a general nephrology clinic.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This was a retrospective chart review of 44 patients with CKD stages 2 to 4, who were managed in the general nephrology clinic (1996-2001, n = 20) or the CRI clinic (2002-2007, n = 24) for 1 yr before starting renal replacement therapy (RRT). Laboratory parameters, growth, and dialysis access type at time of RRT were compared between the two cohorts.

RESULTS

At RRT, patients from the CRI clinic had better hemoglobin, lower parathyroid hormone and calcium phosphorus product than patients followed in the general nephrology clinic. More patients from the general nephrology clinic had an unplanned initiation of dialysis compared with patients from the CRI clinic (50% versus 10.5%, P < 0.05).

CONCLUSIONS

This indicates that children followed in a multidisciplinary clinic have better outcome variables and are more likely to achieve K/DOQI targets at initiation of dialysis. They are better prepared for dialysis with electively planned catheter insertion or functioning arteriovenous grafts/fistulae.

Chronic kidney disease care delivered by US family medicine and internal medicine trainees: results from an online survey

BACKGROUND

Complications of chronic kidney disease (CKD) contribute to morbidity and mortality. Consequently, treatment guidelines have been developed to facilitate early detection and treatment. However, given the high prevalence of CKD, many patients with early CKD are seen by non-nephrologists, who need to be aware of CKD complications, screening methods and treatment goals in order to initiate timely therapy and referral.

METHODS

We performed a web-based survey to assess perceptions and practice patterns in CKD care among 376 family medicine and internal medicine trainees in the United States. Questions were focused on the identification of CKD risk factors, screening for CKD and associated co-morbidities, as well as management of anemia and secondary hyperparathyroidism in patients with CKD.

RESULTS

Our data show that CKD risk factors are not universally recognized, screening for CKD complications is not generally taken into consideration, and that the management of anemia and secondary hyperparathyroidism poses major diagnostic and therapeutic difficulties for trainees.

CONCLUSION

Educational efforts are needed to raise awareness of clinical practice guidelines and recommendations for patients with CKD among future practitioners.

Barriers to successful care for chronic kidney disease

Background

The National Kidney Foundation has formulated clinical practice guidelines for patients with chronic kidney disease (K/DOQI). However, little is know about how many patients actually achieve these goals in a dedicated clinic for chronic kidney disease.

Methods

We performed a cross-sectional analysis of 198 patients with an estimated glomerular filtration rate of less than 30 ml/min/1.73 m² and determined whether K/DOQI goals were met for calcium, phosphate, calcium-phosphate product, parathyroid hormone, albumin, bicarbonate, hemoglobin, lipids, and blood pressure.

Results

We found that only a small number of patients achieved K/DOQI targets. Recent referral to the nephrologist, failure to attend scheduled clinic appointments, African American ethnicity, diabetes, and advanced renal failure were significant predictors of low achievement of K/DOQI goals.

Conclusion

We conclude that raising awareness of chronic kidney disease and K/DOQI goals among primary care providers, early referral to a nephrologist, the exploration of socioeconomic barriers and cultural differences, and both patient and physician education are critical to improve CKD care in patients with Stage 4 and 5 CKD.

CKD Progression and Mortality Among Older Patients With Diabetes

BACKGROUND

Chronic kidney disease (CKD) is clearly associated with an increased risk for adverse outcomes; however, the cumulative impact of renal and cardiac complications in high-risk populations is not known. In addition, little is known about patterns of nephrology care in patients with CKD.

METHODS

We conducted a retrospective longitudinal cohort study assessing CKD prevalence and progression, associations with all-cause mortality, and variations in patterns of nephrology consultation in older patients with diabetes in a vertically integrated health care system.

RESULTS

A total of 12,570 patients within a 7-Veterans Affairs hospital service network in 1998 to 1999 were identified by means of computerized records. Nearly half (48%) were affected with CKD; most had mild to moderate CKD. After an observation period of 3 years, mortality rates in those unaffected with CKD were high (4.7 deaths/100 person-years) and increased substantially with progressive CKD (eg, 20.1 deaths/100 person-years with an estimated glomerular filtration rate [GFR] of 15 to 29 mL/min/1.73 m2 [0.25 to 0.48 mL/s/1.73 m2]). Only 7.2% of patients with CKD had a nephrology visit during the entire 5-year study period. Although visits increased with more advanced CKD, only 32% of patients with an estimated GFR of 15 to 29 mL/min/1.73 m2 had been seen in a nephrology clinic. We also found that nephrology referrals were driven preferentially by elevations in serum creatinine levels, rather than low GFRs.

CONCLUSION

Many in this cohort of older patients with diabetes are affected with CKD. Mortality rates are high, and mortality risks associated with CKD amplify those of other risk factors. Nephrology visits are low and may represent an unexploited resource for improving CKD management. Underrecognition of CKD likely is related to overestimation of kidney function by relying on serum creatinine level in elderly patients.