Improved nephrology referral of chronic kidney disease patients: potential role of smartphone apps

Diagnosis of Chronic Kidney Disease and Assessing Glomerular Filtration Rate

Chronic kidney disease (CKD) is a silent progressive disease. It is diagnosed by assessing filtration and markers of kidney damage such as albuminuria. The diagnosis of CKD should include not only assessing the glomerular filtration rate (GFR) and albuminuria but also the cause. The CKD care plan should include documentation of the trajectory and prognosis. The use of a combination of serum cystatin C and creatinine concentration offers a more accurate estimation of GFR. Social determinants of health are important to address as part of the diagnosis because they contribute to CKD disparities.

Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease

Chronic kidney disease (CKD) and kidney failure are global health problems associated with morbidity, mortality and healthcare costs, with unequal access to kidney replacement therapy between countries. The diversity of guidelines concerning referral from primary care to a specialist nephrologist determines different outcomes around the world among patients with CKD where several guidelines recommend referral when the glomerular filtration rate (GFR) is <30 mL/min/1.73 m2 regardless of age. Additionally, fixed non-age-adapted diagnostic criteria for CKD that do not distinguish correctly between normal kidney senescence and true kidney disease can lead to overdiagnosis of CKD in the elderly and underdiagnosis of CKD in young patients and contributes to the unfair referral of CKD patients to a kidney specialist. Non-age-adapted recommendations contribute to unnecessary referral in the very elderly with a mild disease where the risk of death consistently exceeds the risk of progression to kidney failure and ignore the possibility of effective interventions of a young patient with long life expectancy. The opportunity of mitigating CKD progression and cardiovascular complications in young patients with early stages of CKD is a task entrusted to primary care providers who are possibly unable to optimally accomplish guideline-directed medical therapy for this purpose. The shortage in the nephrology workforce has classically led to focused referral on advanced CKD stages preparing for kidney replacement, but the need for hasty referral to a nephrologist because of the urgent requirement for kidney replacement therapy in advanced CKD is still observed and changes are required to move toward reducing the kidney failure burden. The Kidney Failure Risk Equation (KFRE) is a novel tool that can guide wiser nephrology referrals and impact patients.

Validation of Administrative Coding and Clinical Notes for Hospital-Acquired Acute Kidney Injury in Adults

Acute kidney injury (AKI) is potentially catastrophic and commonly seen among inpatients. In the United States, the quality of administrative coding data for capturing AKI accurately is questionable and needs to be updated. This retrospective study validated the quality of administrative coding for hospital-acquired AKI and explored the opportunities to improve the phenotyping performance by utilizing additional data sources from the electronic health record (EHR). A total of34570 patients were included, and overall prevalence of AKI based on the KDIGO reference standard was 10.13%, We obtained significantly different quality measures (sensitivity.-0.486, specificity:0.947, PPV.0.509, NPV:0.942 in the full cohort) of administrative coding from the previously reported ones in the U.S. Additional use of clinical notes by incorporating automatic NLP data extraction has been found to increase the AUC in phenotyping AKI, and AKI was better recognized in patients with heart failure, indicating disparities in the coding and management of AKI.

Management of chronic kidney disease in type 2 diabetes: screening, diagnosis and treatment goals, and recommendations

Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at high risk of CKD progression and cardiovascular (CV) disease. Prevalence of CKD in patients with T2D is currently around 40% and continues to grow. The increasing number of people with CKD and T2D will ultimately have a significant impact upon health resource use and costs of care for people with T2D. Management of CKD in patients with T2D aims to preserve kidney function to reduce the risk of end-stage kidney disease, CV events, and mortality. Evidence-based recommendations for the treatment of patients with CKD and T2D are provided by several international and national organizations and recommend several lifestyle and pharmacological approaches to help prevent or delay the progression of CKD in patients with T2D. Guidelines include regular screening of patients with T2D for CKD using spot urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (at least annually and at least twice a year if UACR >300 mg/g). Additionally, assessment of vascular complications, together with interventions designed to improve glycemic control and lipid levels, maintain healthy body weight, and optimize blood pressure should be performed. Medications shown to slow progression of CKD include renin-angiotensin system inhibitors, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists, and, more recently, selective, non-steroidal mineralocorticoid receptor antagonists. This review highlights the ongoing challenges facing primary care providers in the management of CKD in patients with T2D including the consideration of comorbidities, adoption of new treatment options, and implementation of individualized care. Achieving consensus for optimal treatment of this disease is critical in providing consistent and appropriate care for all patients. Strategies to improve outcomes should also include use of clear referral criteria, use of a multi-disciplinary approach, and patient education.

[Impact of the COVID-19 pandemic on Spanish Nephrology Services]

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has required a rapid and drastic transformation of hospitals, and consequently also of Spanish Nephrology Units, to respond to the critical situation. The Spanish Society of Nephrology conducted a survey directed to the Heads of Nephrology Departments in Spain that addressed the reorganisation of Nephrology departments and activity during the peak of COVID-19 pandemic. The survey has been focused on the integration of nephrologists in COVID-19 teams, nephrology inpatient care activities (elective admissions, kidney biopsies), the performance of elective surgeries such as vascular accesses or implantation of peritoneal catheters, the suspension of kidney transplantation programmes and the transformation of nephrology outpatient clinics. This work details the adaptation and transformation of nephrology services during the COVID-19 pandemic in Spain. During this period, elective admissions to Nephrology Services, elective surgeries and biopsies were suspended, and the kidney transplant programme was scaled back by more than 75%. It is worth noting that outpatient nephrology consultations were carried out largely by telephone. In conclusion, the pandemic has clearly impacted clinical activity in Spanish Nephrology departments, reducing elective activity and kidney transplants, and modifying activity in outpatient clinics. A restructuring and implementation plan in Nephrology focused on telemedicine and/or virtual medicine would seem to be both necessary and very useful in the near future.

Impact of COVID-19 pandemic in Spanish Nephrology Servicesservices impact of the pandemic on COVID-19 Spanish Nephrology Services☆

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has required a rapid and drastic transformation of hospitals, and consequently also of Spanish Nephrology Units, to respond to the critical situation. The Spanish Society of Nephrology conducted a survey directed to the Heads of Nephrology Departments in Spain that addressed the reorganisation of Nephrology departments and activity during the peak of COVID-19 pandemic. The survey focused on the integration of nephrologists in COVID-19 teams, nephrology inpatient care activities (elective admissions, kidney biopsies), the performance of elective surgeries such as vascular accesses or implantation of peritoneal catheters, the suspension of kidney transplantation programmes and the transformation of nephrology outpatient clinics. This work details the adaptation and transformation of nephrology services during the COVID-19 pandemic in Spain. During this period, elective admissions to Nephrology Services, elective surgeries and biopsies were suspended, and the kidney transplant programme was scaled back by more than 75%. It is worth noting that outpatient nephrology consultations were carried out largely by telephone. In conclusion, the pandemic has clearly impacted clinical activity in Spanish Nephrology departments, reducing elective activity and kidney transplants, and modifying activity in outpatient clinics. A restructuring and implementation plan in Nephrology focused on telemedicine and/or virtual medicine would seem to be both necessary and very useful in the near future.