The medical and economical advantages of early referral of chronic renal failure patients to renal specialists

Current Management Strategies of Chronic Kidney Disease in Resource-Limited Countries

The incidence and prevalence of chronic kidney disease (CKD) and kidney failure continues to increase worldwide, especially in resource-limited countries. Many countries in this category already have a massive burden of communicable diseases, as well as socio-economic and socio-demographic challenges. The rising CKD burden and exorbitant economic cost associated with treatment are mainly responsible for the alarming mortality rate associated with kidney disease in these regions. There is often poor risk factor (diabetes and hypertension) and CKD awareness in these countries and limited availability and affordability of treatment options. Given these observations, early disease detection and preventive measures remain the best options for disease management in resource-limited settings. Primary, secondary and tertiary preventive strategies need to be enhanced and should particularly include measures to increase awareness, regular assessment to detect hypertension, diabetes and albuminuria, options for early referral of identified patients to a nephrologist and options for conservative kidney management where kidney replacement therapies may not be available or indicated. Much is still needed to be done by governments in these regions, especially regarding healthcare funding, improving the primary healthcare systems and enhancing non-communicable disease detection and treatment programs as these will have effects on kidney care in these regions.

Analysis of Patient Flow into Dialysis: Role of Education in Choice of Dialysis Modality

♦ Background

Despite advances in predialysis care, morbidity and mortality remain high.

♦ Objectives

To analyze end-stage renal disease (ESRD) patient demographics and clinical data on education on dialysis treatment options, type of chronic renal replacement therapy (RRT), and effects of planned versus non-planned dialysis start.

♦ Methods

621 patients, from 24 Spanish hospitals, who started RRT in 2002. Peritoneal or vascular access at dialysis initiation was considered “planned.”

♦ Results

304 (49%) patients were non-planned and half of them had prior nephrology follow-up. Of the patients with ≥3 months nephrology follow-up (76% of all), only half were educated on dialysis modalities. Dialysis education was associated with planned start in 73.4% versus 26% in non-educated patients ( p < 0.05), shorter follow-up (55 vs 65 months, p = 0.033), more medical visits in the prior year (6.5 vs 4.4, * p < 0.001), more patients starting peritoneal dialysis (31% vs 8.3%*), and more specific follow-up by ESRD unit versus general nephrology care (63% vs 26%*). Non-planned start was associated with older age (63 vs 60.6 years, p = 0.06), fewer medical visits (4.6 vs 6.4*), less education about modality options, and greater use of hemodialysis (92% vs 75%*). Planned patients had better biochemical parameters at start of dialysis.

♦ Conclusion

Despite nephrology follow-up, half the patients did not have a planned dialysis start. Planned start was associated with better clinical status. More patients chose peritoneal dialysis when educated about dialysis modality options. ESRD-specific units were more likely to provide patient education.

Estimated plasma volume and mortality: analysis from NHANES 1999-2014

BACKGROUND

While estimated plasma volume (ePV) has been studied in some diseases, such as heart failure, the relationship between ePV and all-cause or cause-specific mortality remains unexplored. Therefore, we investigated the association between ePV and all-cause, cardiovascular (CV), and cancer-related mortality among adults in the US.

METHOD

We used the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2014 and included participants older than 18 years. Mortality data were obtained from the National Death Index and matched to the NHANES participants. ePV was derived using Strauss formula. Cox proportional hazard models were fit to estimate hazard ratios for all-cause and cause-specific mortality without and with adjustment for potential confounders.

RESULTS

Of the 42,705 participants, 5194 died (1121 CV deaths) during mean follow-up of 8.0 (range 0-16.7) years. Mean ± SD age and ePV of the participants were 47.2 ± 19.4 years and 4.2 ± 0.84, respectively. In unadjusted models, 1 unit increase in ePV was associated with 29%, 32%, and 16% increased risk in all-cause (HR 1.29; 95% CI 1.24, 1.35), CV (HR 1.32; 95% CI 1.22, 1.43), and cancer-related (HR 1.16; 95% CI 1.05, 1.27) mortality. Risk remained high in adjusted models (all-cause HR 1.24; 95% CI 1.18, 1.30; CV HR 1.22; 95% CI 1.11, 1.34; cancer-specific HR 1.24; 95% CI 1.10, 1.39). When comparing the highest and lowest ePV quartiles, similar results were noted (adjusted all-cause HR 1.64; 95% CI 1.45, 1.86; CV HR 1.52; 95% CI 1.19, 1.93; cancer HR 1.85; 95% CI 1.38, 2.49).

CONCLUSION

An increase in ePV was associated with increased all-cause and cause-specific mortality. Further studies are needed to explore the mechanism of this relationship and translation into a better outcome.

Factors associated with late presentation of patients with chronic kidney disease in nephrology consultation in Cameroon-a descriptive cross-sectional study

BACKGROUND

Late presentation (LP) of chronic kidney disease (CKD) patients to nephrologist is a serious problem worldwide with persistent high prevalence despite known benefits of early nephrology care.

OBJECTIVE

Determine the prevalence and factors associated with LP of CKD patients to nephrologists in Cameroon.

METHODS

A cross-sectional study from October 2015 to May 2016 at the nephrology units of the Douala General and Laquintinie hospitals, including all consenting incident CKD patients. Data collected were: socio-demographic, search of CKD diagnostic criteria during prior follow up, therapeutic itinerary, clinical and biological parameters at presentation, knowledge on CKD and attitude towards dialysis. LP was defined as eGFR < 30 ml/min/1.73 m2. It was physician-related whenever no CKD screening was done in the presence of risk factor or no referral to nephrologists at early stages; patient-related whenever patients did not have recourse to hospital care while symptomatic or disrespected a referral decision. p value <.05.

RESULTS

We included 130 patients, mean age 53.10 ± 14.66 years, 60.77% males, 58.70% were referred by internal medicine physicians and 10% had recourse to complementary and alternative medicine (CAM). At presentation, 70.80% were symptomatic, 53% had CKD stage five, 86.12% were poorly graded on knowledge and 49% had a negative attitude towards dialysis. The prevalence of LP was 73.90%, 50% was physician-related, 44.79% patient-related and 5.21% both. Being accompanied (p = .038), a low level of education (p = .025) and recourse to CAM (p = .008) were associated with LP.

CONCLUSION

LP is high in Cameroon, attributed to physician's practical attitudes and patient's socio-cultural behaviors and economic conditions.

[Initiating hemodialysis in Morocco: Impact of late referral]

INTRODUCTION

End-stage renal disease (ESRD) is a major public health concern in Morocco with an incidence in constant progression according to MAGREDIAL "Morocco Dialysis Registry". Patients are often sent late to nephrologists, which is a source of complications recognized in several countries. For these reasons, we tried to evaluate, in our context, the prevalence and factors of this late referral (LR).

METHODS

This is a retrospective study which included all patients initiating hemodialysis between January 2007 and December 2015. We found the history of following these patients and sought their clinical characteristics at the time of setting hemodialysis.

RESULTS

During the study, 318 patients were admitted for management of ESRD. Their average age was 54.31 years and diabetic nephropathy was the most common cause of 41% of cases. Only 105 patients (33%) had a nephrological follw up in almost two thirds of cases, hemodialysis was started by using a temporary central venous catheter especially femoral. we have identified five factors associated with LR: nemia, hypoalbuminemia, inflammatory syndrome, a longer initial hospitalization, a greater use of temporary catheterization as first access.

CONCLUSION

LR patients with ESRD remains very common in our context. It is about 67% and complicates implementation hemodialysis patients with anemia and more use of central catheters that are predictors of mortality previously described in the literature. Economically, LR significantly increases the cost of care by significantly increasing the duration of hospitalization.

Geographic variation and neighborhood factors are associated with low rates of pre-end-stage renal disease nephrology care

Geographic variation of pre-end-stage renal disease (pre-ESRD) nephrology care has not been studied across the United States. Here we sought to identify geographic differences in pre-ESRD care, assess for county-level geographic and sociodemographic risk factors, and correlate with patient outcomes using facility-level mortality. Patients from 5387 dialysis facilities across the United States from 2007 to 2010 were included from the Dialysis Facility Report. Marginal generalized estimating equations were used for modeling with geographic cluster analysis to detect clusters of facilities with low rates of pre-ESRD care. On average, 67% of patients received pre-ESRD care in the United States but with significant variability across regions ranging from 3 to 99%. Five geographic clusters of facilities with low rates of pre-ESRD care were the metropolitan areas of San Francisco, Los Angeles, Chicago, Miami, and Baltimore, along with Southern states along the Mississippi River. Dialysis facilities with the lowest rates of pre-ESRD care were more likely to be located in urban counties with high African-American populations and low educational attainment. A 10% higher proportion of patients receiving pre-ESRD care was associated with 1.3% lower patient mortality as reflected by facility-level mortality. Thus, geographic and sociodemographic factors can be used to design quality improvement initiatives to increase access to nephrology care nationwide and improve patient outcomes.

Preemptive kidney transplantation: analysis of kidney grafts from the same donor

BACKGROUND

From November 2003 to December 2012, in the Gdańsk Center, 64 patients received preemptive transplantation (PET). PET comprised 8% of 794 kidney transplantations performed during this time. The benefits for individual patients and for the health care system are discussed.

METHODS

This study compares the outcomes of these PET patients who had their kidney pairs transplanted after a variable duration of dialysis (PTD), a total of 51 pairs.

RESULTS

The mean Charlson comorbidity index was 2.57 vs 3.04 (P > .05) for the PET and PTD groups, respectively. Both groups did not differ significantly with respect to 1-year patient and graft survivals, and incidences of acute rejection. Five (9.8%) PET patients and 20 (39%) PTD patients experienced delayed graft function (P < .05). The graft function (serum creatinine/4p MDRD) 1 year after transplantation was similar in both groups (1.42/53.7 vs 1.43/57.4; mg/dL/mL/min/1.73 m(2)). More PET patients continued normal professional activities or education before and after transplantation (P < .05).

CONCLUSIONS

Our single-center results confirmed that for both medical and socioeconomic reasons, PET is an optimal mode of renal replacement therapy.

Early nephrology referral reduces the economic costs among patients who start renal replacement therapy: a prospective cohort study in Korea

Background

The nature of cost-saving effects of early referral to a nephrologist in patients with chronic kidney disease (CKD) is not fully evaluated. We evaluated the health care costs before and after dialysis according to the referral time.

Methods

A total of 879 patients who were newly diagnosed as having end-stage renal disease from August 2008 to June 2011 were prospectively enrolled. The early referral (ER) group was defined as patients who were referred to a nephrologist more than a year before dialysis and had visited a nephrology clinic 2 or more times. Patients whose referral time was less than a year were considered the late referral (LR) group. Information about medical costs was acquired from the claim data of the Korea Health Insurance Review and Assessment Service.

Results

The total medical costs during the first 12 months after the initiation of dialysis were not different between the 526 ER patients and the 353 LR patients. However, the costs of the ER patients during the first month were significantly lower than those of the LR patients (ER vs. LR: 3029±2219 vs. 3438±2821 US dollars [USD], P = 0.025). The total 12-month health care costs before the initiation of dialysis were significantly lower in the ER group (ER vs. LR: 6206±5873 vs. 8610±7820 USD, P<0.001). In the multivariate analysis, ER significantly lowered the health care costs during the 12 months before (2534.0±436.2 USD, P<0.001) and the first month (428.5±172.3 USD, P = 0.013) after the initiation of dialysis.

Conclusions

The ER of patients with CKD to a nephrologist is associated with decreased medical costs during the pretreatment period of renal replacement therapy and the early period of dialysis initiation.

The associations between race and geographic area and quality-of-care indicators in patients approaching ESRD

BACKGROUND AND OBJECTIVES

Pre-ESRD care is an important predictor of outcomes in patients undergoing long-term dialysis. This study examined the extent of variation in receiving pre-ESRD care and black-white disparities across urban and rural counties.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Participants were 404,622 non-Hispanic white and black patients aged >18 years who began dialysis between 2005 and 2010 and resided in 3076 counties from the U.S. Renal Data System. The counties were grouped into large metropolitan, medium/small metropolitan, suburban, and rural counties. Pre-ESRD care indicators included receipt of nephrologist care at least 6 or 12 months before ESRD, dietitian care, use of arteriovenous fistula at first outpatient dialysis session, and use of erythropoiesis-stimulating agents (ESAs) in patients with hemoglobin level < 10 g/dl.

RESULTS

Large metropolitan and rural counties had lower percentages of patients who received pre-ESRD nephrologist care (25.7% and 26.9% for nephrologist care > 12 months), compared with the higher percentage in medium/small metropolitan counties (31.6%; both P<0.001). For both races, nonmetropolitan patients had poorer access to dietitian care and lower ESA use than metropolitan patients. Consistently in all four geographic areas, black patients received less care than their white counterparts. The unadjusted odds ratios of black versus white patients in receiving nephrologist care for >12 months before ESRD were 0.66 (95% confidence interval [CI], 0.61-0.72) in large metropolitan counties and 0.79 (95% CI, 0.69-0.90) in rural counties. The patterns remained, albeit attenuated, after adjustment for patient factors.

CONCLUSIONS

The receipt of pre-ESRD care, with blacks receiving less care, varies among geographic areas defined by urban/rural characteristics.

Prevalence of chronic kidney diseases and its determinants among perimenopausal women in a rural area of North India: A community-based study

The burden of noncommunicable diseases is rising in India. A high prevalence of lifestyle-related diseases in perimenopausal women in the community makes them vulnerable to chronic kidney diseases (CKD). A cross-sectional community-based study was carried out among women >35 years of age in the village of Ballabgarh, Haryana (north India). Eligible women were selected by the probability proportionate to size sampling method. Estimation of glomerular filtration rate (GFR) was carried out by using the age- and body surface area (BSA)-adjusted Cockcroft–Gault (CG) and modification of diet in renal disease (MDRD) equations. Association of risk factors such as obesity, hyperlipidemia, hypertension, and diabetes mellitus with CKD was also assessed using multivariate logistic regression analysis. A total of 455 women were studied. The prevalence of low GFR (<60 mL/min/1.73 m²) by the CG/BSA equations and MDRD equation was found to be 18.2% (95% confidence interval 14.6, 21.8) and 5.9% (95% confidence interval 3.7, 8.1), respectively. Obesity (odds ratio 15.5) (P = 0.002), hyperlipidemia (odds ratio: 2.5) (P = 0.017), and age (P < 0.001) were significantly associated with reduced GFR on multivariate logistic regression analysis. This study observed a high prevalence of CKD and its risk factors among perimenopausal women in a rural community in north India. The study highlights the need of a multipronged, community-based intervention strategy that includes a high-risk screening approach and awareness generation about CKD and its risk factors in the community.

Timing of nephrology referral: influence on mortality and morbidity in chronic kidney disease

Background

Few studies in India as well as in most developing countries have compared the mortality and morbidity rates between chronic kidney disease patients who were referred early to nephrologists and those who were referred late.

Objectives

To study the mortality and morbidity patterns and to compare the various clinical parameters between the abovementioned early and late referrals.

Patients and Methods

Fifty consecutive chronic kidney disease patients were followed up for one year. They were then classified as early referral (patients who underwent dialysis more than three months after the referral) and late referral (patients who underwent dialysis within three months of the referral). Clinical, laboratory parameters, and mortality patterns were compared between the two groups.

Results

The blood pressure, hemoglobin, glomerular filtration rate, and calcium and phosphate values were better in the early referral group. Among the 24 complications that occurred, 17 (70.8%) were seen among the patients who were referred late. Among the 13 deaths that occurred, only one belonged to the early referral group.

Conclusions

We observed that the mortality rate and clinical parameters were better in patients who were referred early to nephrologists.

Managing chronic kidney disease in type 2 diabetes in family practice

Diabetic nephropathy is the leading cause of stage 5 chronic kidney disease (CKD) and occurs in 1 in 9 persons with newly diagnosed type 2 diabetes. Screening should begin at the time of type 2 diabetes diagnosis to detect the presence of a decreased estimated glomerular filtration rate (GFR) and/or an elevated albumin excretion rate. The estimated GFR can be used to stage CKD, assess cardiovascular risk, and develop treatment strategies. A multifaceted treatment plan delivered using a collaborative care approach that fosters person self-management is important. Glucose-lowering agents should be selected based on renal function and titrated to achieve an A1c less than 7.0%. Lipid-lowering therapy with a statin should be utilized to achieve a low-density lipoprotein cholesterol less than 100 mg/dL, possibly less than 70 mg/dL. An angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or direct renin inhibitor, typically in combination with other antihypertensive therapies, is recommended for persons with hypertension, microalbuminuria/macroalbuminuria, and type 2 diabetes, as this approach has been shown to be renoprotective. Angiotensin-converting inhibitors have an additional benefit of improving cardiovascular outcomes in CKD.

Predialysis nephrology care and costs in elderly patients initiating dialysis

BACKGROUND

Access to nephrology care before initiation of chronic dialysis is associated with improved outcomes after initiation. Less is known about the effect of predialysis nephrology care on healthcare costs and utilization.

METHODS

We conducted retrospective analyses of elderly patients who initiated dialysis between January 1, 2000 and December 31, 2001 and were eligible for services covered by the Department of Veterans Affairs. We used multivariable generalized linear models to compare healthcare costs for patients who received no predialysis nephrology care during the year before dialysis initiation with those who received low- (1-3 nephrology visits), moderate- (4-6 visits), and high-intensity (>6 visits) nephrology care during this time period.

RESULTS

There were 8022 patients meeting inclusion criteria: 37% received no predialysis nephrology care, while 24% received low, 16% moderate, and 23% high-intensity predialysis nephrology care. During the year after dialysis initiation, patients in these groups spent an average of 52, 40, 31, and 27 days in the hospital (P < 0.001), respectively, and accounted for an average of $103,772, $96,390, $93,336, and $89,961 in total healthcare costs (P < 0.001), respectively. Greater intensity of predialysis nephrology care was associated with lower costs even among patients whose first predialysis nephrology visit was ≤ 3 months before dialysis initiation. Patients with greater predialysis nephrology care also had lower mortality rates during the year after dialysis initiation (43%, 38%, 28%, and 25%, respectively, P < 0.001).

CONCLUSIONS

Greater intensity of predialysis nephrology care was associated with fewer hospital days and lower total healthcare costs during the year after dialysis initiation, even though patients survived longer.

Underestimation of impaired kidney function with serum creatinine

Serum creatinine (SCr) levels are frequently used as a screening test to assess impaired renal function; however, patients can have significantly decreased glomerular filtration rate (GFR) with normal SCr values and making the recognition of kidney dysfunction more difficult. Hence, this study was designed to determine the extent of misclassification of the patients who have significantly reduced GFR as calculated by reexpressed four variable modification of diet in renal disease (MDRD) equation but, normal range of SCr. The study included 1040 in and out patients referred by physicians for serum creatinine measurement. When an exclusion criterion was applied 928 patients were qualified for the study. SCr was measured in 928 patients by a Roche kinetic compensated Jaffe's assay. GFR was calculated using reexpressed four variable MDRD study equation. Of the 928 patients 270 (29.1%) had renal dysfunction on the basis of eGFR (<60 ml/min/1.73 m(2)). However, with SCr only 162 (17.5%) patients had abnormal renal function (>1.5 mg/dl) and SCr values misrepresented (108) 11.6% patients with impaired kidney function. In addition, more females, about 15% were failed to detect by SCr method in contrast to males of 9%. This study documented that, a large proportion of patients with impaired renal function are not diagnosed if clinicians rely solely on normal SCr as evidence of normal renal function. Inclusion of eGFR calculated by re-expressed 4 variable MDRD equation may facilitates the early identification and intervention of patients with renal impairment.

Addressing racial and ethnic disparities in live donor kidney transplantation: priorities for research and intervention

One potential mechanism for reducing racial/ethnic disparities in the receipt of kidney transplants is to enhance minorities' pursuit of living donor kidney transplantation (LDKT). Pursuit of LDKT is influenced by patients' personal values, their extended social networks, the health care system, and the community at large. This review discusses research and interventions promoting LDKT, especially for minorities, including improving education for patients, donors, and providers, using LDKT kidneys more efficiently, and reducing surgical and financial barriers to transplant. Future directions to increase awareness of LDKT for more racial/ethnic minorities also are discussed including developing culturally tailored transplant education, clarifying transplant-eligibility practice guidelines, strengthening partnerships between community kidney providers and transplant centers, and conducting general media campaigns and community outreach.

Aspirin use and risk of type 2 diabetes in apparently healthy men

BACKGROUND

Epidemiologic data on aspirin use and the risk of diabetes are limited. The Physician's Health Study has accumulated 22 years of follow-up data, including 5 years of randomized data, from 22,071 apparently healthy men.

METHODS AND RESULTS

At baseline and in yearly follow-up questionnaires, participants self-reported a history of diabetes, aspirin use, and various lifestyle factors. To evaluate the association between aspirin use and risk of subsequent diabetes, we used a Cox proportional hazards model with time-varying regression coefficients. During the 22 follow-up years, 1719 cases of diabetes were reported. The multivariable-adjusted hazard ratio of developing diabetes was 0.86 (95% confidence interval [CI], 0.77-0.97) for those who self-selected any aspirin. During the 5 years of randomized treatment, 318 cases of diabetes were observed, with a hazard ratio of 0.91 (95% CI, 0.73-1.14) for those randomized to aspirin.

CONCLUSION

Our data suggest a small but not significant decrease in the risk of diabetes during 5 years of randomized comparison of 325 mg of aspirin every other day. This trend was continued during 22 years of follow-up, indicating that self-selection of any use of aspirin is associated with a significant, approximately 14% decrease in the risk of diabetes. Decreased risk of type 2 diabetes may be added to the list of the clinical benefits of aspirin.

Optimal Referral to Pre-Dialysis Services: One Center's Experience

The number of patients receiving renal replacement therapy in the United Kingdom is rapidly rising. Chronic kidney disease (CKD) is a worldwide public health problem with significant comorbidity and mortality. Several organizational guidelines have been developed in an attempt to identify when appropriate referral to nephrology services should occur; however, many of these guidelines provide conflicting recommendations on referral. Recent surveys suggest that more than 30% of patients with CKD are referred later than the ideal. Late referral of patients with CKD is associated with increased patient morbidity and mortality, increased need for and duration of hospital admission, and increased initial costs of care following commencement of dialysis. Benefits of early referral include the identification and treatment of reversible causes of renal impairment and management of the multiple coexisting conditions associated with CKD. Referral time also affects the choice of modality of treatment.

Patients and their families should receive sufficient information regarding the nature of their CKD and options for treatment so that they can make informed decisions concerning their care. Literature addressing the timing of referral to low-clearance or pre-dialysis clinics is limited. Existing data suggest that such clinics and patient education programs may improve the medical care of patients, promote greater patient involvement in the selection of the mode of dialysis, reduce the need for “urgent start” dialysis, and improve short-term survival and quality of life after initiation of dialysis. Audit of our pre-dialysis clinic has demonstrated improved patient outcomes, and we view this service as an essential component of the patient pathway.

Optimal Referral is Early Referral

The number of patients receiving renal replacement therapy in the United Kingdom is rapidly rising. Chronic kidney disease (CKD) is a worldwide public health problem with significant comorbidity and mortality. Several organizational guidelines have been developed in an attempt to identify when appropriate referral to nephrology services should occur; however, many of these guidelines provide conflicting recommendations on referral. Recent surveys suggest that more than 30% of patients with CKD are referred later than is ideal. Late referral of patients with CKD is associated with increased patient morbidity and mortality, increased need for and duration of hospital admission, and increased initial costs of care following commencement of dialysis. Additional benefits of early referral include identifying and treating reversible causes of renal impairment and managing the multiple coexisting conditions associated with CKD. Referral time also affects the choice of treatment modality. Patients and their families should receive sufficient information regarding the nature of their CKD and the options for treatment so that they can make informed decisions concerning their care. Literature addressing when to refer to low-clearance or pre-dialysis clinics is limited. Existing data suggest that such clinics and patient education programs may facilitate improved medical care for patients, greater patient involvement in selection of the mode of dialysis, reduction in the need for “urgent start” dialysis, and improved short-term survival and quality of life after initiation of dialysis. Audit of our pre-dialysis clinic has demonstrated improved patient outcomes, and we view the early-referral service as an essential component of the patient pathway.

Improving Preemptive Transplant Education to Increase Living Donation Rates: Reaching Patients Earlier in Their Disease Adjustment Process

Patients who receive a preemptive kidney transplant before starting dialysis avoid the medical complications related to dialysis and have the highest graft success and lowest mortality rates. Because only 2.5% of incident patients receive kidney transplants preemptively, improved psychosocial education may assist more patients in accessing preemptive transplant. This article outlines (1) unique psychosocial issues affecting patients with chronic kidney disease stage 4 (glomerular filtration rates >20 mL/min per 1.73 m2) and (2) how an educational program about preemptive living donor transplant should be designed and administered to increase access to this treatment option. Early referral patients may be overwhelmed in coping with and learning about their disease and, therefore, not ready to make a treatment decision, or they may be highly motivated to obtain a transplant to avoid dialysis and return to a normal life. An education program that defines the quality-of-life and health benefits possible with early transplant is outlined. The program is focused on minimizing the disruption of starting 2 treatment techniques and maximizing early transplant health, graft survival, employability, and retention of insurance coverage. Once the benefits of preemptive living donor transplant are outlined, educators can focus on demystifying the living donor evaluation process and assisting interested patients in planning how to find a living donor. To reach all patients, especially racial minorities, education about preemptive transplant should be available in primary-care physicians' and community nephrologists' offices, at dialysis centers, and through other kidney organizations.

Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low

BACKGROUND

UK, US and European guidelines recommend the decision to initiate dialysis should be based on a combination of measurements of kidney function, nutritional status and clinical symptoms. Such recommendations assume an accurate and reproducible measure of glomerular filtration rate (GFR).

METHODS

Prospective study of 97 patients with chronic kidney disease (CKD) and serum creatinine >200 micromol/l (2.26 mg/dl) who between them contributed 388 24 h urine collections. Our main outcome measure was the number of patients with low residual renal function identified by different tests, using widely accepted thresholds. We calculated sensitivity, specificity, positive and negative predictive values and receiver operating characteristic curves for each comparison using a combined urea and creatinine clearance of <15 ml/min to indicate the likely presence of end stage renal disease (CKD stage 5).

RESULTS

Seventy five patients had a combined urea and creatinine clearance <15 ml/min during the study. Using the highest measurement of serum creatinine for each patient, the best of the prediction equations was the 4-variable modification of diet in renal disease (MDRD) equation (area under ROC curve 0.93). This was followed by Kt/V (AUC 0.91) and Cockroft Gault with and without correction for ideal body weight (AUC 0.89). Further analyses showed that the 4-variable MDRD equation had higher NPV (64%) but lower PPV (89%) than the other tests (NPV 40-49%, PPV 92-100%), for identifying patients whose combined clearance was <15 ml/min.

CONCLUSION

The 4-variable MDRD formula is currently the best available prediction equation for GFR, but will nevertheless over estimate residual renal function when this is significantly impaired in up to 36% cases. Collection of 24 h urine samples may still have a role in the assessment of patients with stages 4 and 5 CKD.

Late referral of patients with chronic kidney disease: no time to waste

The prevalence of patients with chronic kidney disease (CKD) in the US population is approximately 11%, and because of the increase in life expectancy and in diabetic nephropathy incidence, an exponential increase is predicted for the next decades. During the past decade, evidence that the progression of CKD can be attenuated by a multifactorial therapeutic approach has been increasing. However, a substantial percentage of patients with CKD will have progression to CKD stage V (ie, need for renal replacement therapy). Late referral of these patients (ie, <1 to 6 months before the start of renal replacement therapy) has been shown to be associated with higher mortality, morbidity, and costs. However, up to 64% of patients with CKD are still referred late. This review presents the available data on the epidemiology, causes, and consequences of late patient referral. Furthermore, it offers information to prevent late referral, improve CKD patient care, and change clinical practice.

A Single Center Experience in Preemptive Kidney Transplantation

Transplantation is recognized as preemptive if it takes place before the initiation of chronic dialysis. This maneuver has the potential to avoid the morbidity and burden of chronic dialysis. From November 2003 to April 2005, 15 (7 male, 8 female) end-stage renal failure patients of mean age 40 +/- 14.8 years received preemptive grafts from 2 living-related and 13 cadaveric donors, constituting 11.5% of all kidney transplantations performed in our center at that time. The period on the waiting list for preemptive recipients, namely, 2 weeks to 6 months (mean, 2.4 months), was significantly shorter than that of other patients (mean, 13.8 months). The mean creatinine clearance calculated from the Cockroft Gault formula and the mean plasma creatinine level in preemptive recipients before transplantation were 12.7 +/- 3.1 mL/min and 6.6 +/- 0.8 mg/dL, respectively. The donors for preemptive and non-preemptive groups of recipients did not differ significantly in respect to age, gender, and renal function. The mean number of mismatches of 3.73 and 3.25 and the mean total ischemic times of 9.53 +/- 5 and 11.2 +/- 5 hours, in preemptive and non-preemptive groups of recipients, respectively. The incidence of delayed graft function (dialysis in the first week after transplantation) was significantly lower among preemptive recipients (20% versus 42%, respectively). The groups did not differ either in respect to the occurrence of acute rejection episodes or graft and patient survivals. In preemptive patients the mean plasma creatinine levels at 3 and 12 months were 1.37 +/- 0.3 and 1.09 +/- 0.3 mg/dL, and in non-preemptive patients 1.7 +/- 0.5 and 1.4 +/- 0.4 mg/dL. In conclusion, these results are promising, confirming the notion that preemptive kidney transplantation is the optimal treatment for end-stage renal disease patients.

The impact of an out-reach clinic on referral of patients with renal impairment

BACKGROUND

Early diagnosis and prompt treatment of a number of renal diseases may delay renal failure, obviate the need for renal replacement therapy and reduce co-morbidity. The aim of this study was to examine the impact of out-reach renal clinics on patterns of referral of patients with renal impairment to a nephrologist.

METHODS

The number of patients with renal impairment was determined as defined by serum creatinine levels >150 micromol/l in three centres within a single NHS trust over two separate 1-week periods. None of the centres studied has a local nephrologist, however one centre (hospital A) has renal out-reach clinics, another is geographically close to a renal unit (hospital B), while the third unit (hospital C) has no nephrology presence and is geographically furthest from the renal unit. In addition, retrospective as well as follow-up data on the renal function of all patients with renal impairment was collected.

RESULTS

In hospital A, there was a lower proportion of patients with unreferred renal impairment than in the other two hospitals. Within the unreferred patient group there were significantly more patients whose renal function improved during the follow-up period. A considerable proportion of patients with documented deterioration in renal function remained unknown to nephrology services 6 months after initial presentation. Other than the presence of an onsite nephrology service, the only other factor found to be significantly different in those patients not referred to nephrologists was age: as in all three centres, those not referred were significantly older.

CONCLUSION

Inequity of access to renal services is an important obstacle to early referral of patients with impaired renal function. Out-reach renal services provide a model which significantly improves referral patterns.

The short- and long-term impact of multi-disciplinary clinics in addition to standard nephrology care on patient outcomes

BACKGROUND

This two country case control study of incident dialysis patients evaluates the outcomes of patients exposed to formalized multi-disciplinary clinic (MDC) programmes vs standard nephrologist care.

METHODS

Patients commencing dialysis in two centres (Vancouver, Canada and Cremona, Italy) were evaluated at and after dialysis start, as a function of MDC exposure vs nephrologist care alone. Only chronic kidney disease patients, with longer than 3 months of exposure to nephrology care, who had not previously received kidney replacement therapy were included. Study outcomes included laboratory parameters and survival. The MDC was similar in both countries and average exposure was 6-8 h per patient-year, as compared to 2-4 h for standard care. All patients had equal access to resources prior to dialysis and with respect to dialysis start, as all had been referred to the same local nephrology practices.

RESULTS

During the evaluation period 288 patients commenced dialysis after receiving more than 3 months nephrology care prior to dialysis. There were no major demographic differences between the cohorts. Mean duration of nephrology care prior to dialysis was 42 months, and dialysis was initiated at similar low glomerular filtration rate (GFR), though statistically significantly different (7.0 and 8.4 ml/min/m2, P = 0.001). The MDC patients had higher haemoglobin (102 vs 90 g/l, P<0.0001), albumin (37.0 vs 34.8 g/l, P = 0.002) and calcium levels (2.29 vs 2.16 mmol/l, P<0.0001) at dialysis start. Survival was significantly better in the MDC group demonstrated by Kaplan-Meier analysis (P = 0.01). Cox proportional hazards analysis demonstrated standard nephrology clinic vs MDC attendance was a statistically significant independent predictor of death (hazards ratio = 2.17, 95% confidence interval 1.11-4.28) after adjusting for other variables known to impact outcomes.

CONCLUSIONS

This analysis of outcomes in two different countries suggests that despite equal and long exposure to nephrology care prior to dialysis, there appears to be an association of survival advantage for those patients exposed to formalized clinic care in addition to standard nephrologist follow-up. While other known predictors of survival such as adequacy of dialysis and severity of illness measures were not included in the model, those parameters require time on dialysis to be accumulated. Thus, the data do suggest that knowledge of patient status at the time of dialysis start is important. Further research is needed to determine which specific components of care both prior to dialysis and after its commencement are most important with respect to outcomes.

Kidney function in older people: pathology, assessment and management

It is commonly not appreciated that kidney failure is predominantly a disease of older people and that the use of renal replacement therapy (RRT) amongst these patients is increasing rapidly. It is still unclear whether the decline in kidney function with increasing age represents pathology or is part of the normal ageing process. Conventional laboratory approaches to the assessment of kidney function in older people are inadequate, but the use of calculated clearance formulae and serum cystatin C can enable the earlier detection of chronic kidney disease (CKD) in this population. This could facilitate treatment aimed at reducing the progression of kidney disease in older people and improved management of its secondary complications.

Chronic kidney disease: issues and establishing programs and clinics for improved patient outcomes

The spectrum of chronic kidney disease (CKD) extends from the point at which there is slight kidney damage, but normal function, to the point at which patients require either a renal transplant or renal replacement therapy to survive. Epidemiological studies suggest there are approximately 20,000,000 patients with various stages of CKD. These patients have many comorbidities, including cardiovascular disease, hypertension, diabetes, anemia, nutritional and metabolic derangements, and fluid overload. Unfortunately, evidence shows that current CKD care in the United States is suboptimal, and late referral to a nephrologist is often the rule and not the exception. Roles of primary care physicians (PCPs) and nephrologists in the care of patients with CKD remain undefined. Several studies have suggested that care provided by multidisciplinary nephrology teams can improve patient outcomes. Currently, there are published evidence-based clinical practice guidelines for anemia management, nutritional therapy, and vascular access placement, with other CKD guidelines under development. The intent of this review includes providing compelling evidence for earlier screening, identification, and management of patients with CKD; showing that current CKD care is suboptimal; encouraging the development of multidisciplinary teams that provide collaborative care to patients with CKD, suggesting roles for PCPs and nephrologists in the care of these patients; describing CKD initiatives from national organizations; and providing a comprehensive checklist that can guide the development of CKD clinics and programs.

[Estimation of glomerular filtration rate using weight/creatinine formula]

BACKGROUND AND OBJECTIVE

The correct management of patients with chronic renal disease depends on an early diagnosis. The aim of this study was to evaluate the usefulness, in the daily clinical practice, of the weight/creatinine formula as an indirect measurement of glomerular filtration.

PATIENTS AND METHOD

1,025 ambulatory patients were referred to the Nephrology Laboratory for basic blood and urine analysis. Creatinine clearance was calculated with the standard formula.

RESULTS

A good correlation between the creatinine clearance adjusted for the corporal surface and that estimated by the weight/creatinine formula was observed, especially when creatinine levels were between 1.5-3 mg/dl and patients were older than 60 years. The mean difference between both methods was 6.3 (14.5) ml/min for males and 2.4 (10.5) ml/min for females. The weight/creatinine formula had a sensitivity of 91% and a specificity of 80% to detect a clearance below 50 ml/min.

CONCLUSIONS

The weight/creatinine formula underestimates the clearance for normal creatinine values but fits quite well for creatinine levels between 1.5-3 mg/dl, mainly in patients older than 60 years. Although the estimation of clearance through this formula could be inaccurate, in most cases this is clinically irrelevant. Moreover, such a simple formula could avoid potential mistakes appearing at the time of evaluating renal function only by the serum creatinine.

Quality of prereferral care in patients with chronic renal insufficiency

BACKGROUND

Appropriate care in chronic renal insufficiency (CRI) includes blood pressure and diabetes control, as well as the investigation and management of anemia, acidosis, and bone disease. There is a lack of data on the control of these parameters at the time of referral to a nephrologist. Similarly, early referral has been emphasized in the literature, yet very little published has examined current referral patterns.

METHODS

A single-center retrospective/prospective review of all new outpatient referrals to nephrologists in Halifax, Canada, in 1998 and 1999 was conducted to identify patients with CRI (serum creatinine > 1.6 mg/dL [141 micromol/L] for men or >1.2 mg/dL [106 micromol/L] for women). Quality of prereferral care was based on data from the initial clinic visit.

RESULTS

Of 1,050 charts reviewed, 411 patients met the study criteria. Twenty-six percent of patients had diabetes mellitus, 18% were referred with a calculated glomerular filtration rate less than 15 mL/min, and blood pressure was optimally controlled (<130 mm Hg systolic and <80 mm Hg diastolic) in only 24%. Only 44% of patients were administered an angiotensin-converting enzyme inhibitor. Patients were administered an average of 1.9 antihypertensive agents. Significant anemia (hemoglobin < 10 g/dL) was present in 21%, and appropriate investigations were performed in only 35% of these patients. Calcium levels less than 8.6 mg/dL (2.15 mmol/L) were found in 19% of patients, and only 14% of these patients were started on calcium supplement therapy. Phosphate levels greater than 5.0 mg/dL (1.6 mmol/L) were seen in 20% of patients, and 14% of these patients were on phosphate-binder therapy. Parathyroid hormone levels were more than five times normal values in 18% of patients, and 25% of patients had bicarbonate levels less than 23 mmol/L.

CONCLUSIONS

A significant proportion of patients referred with CRI receive inadequate prereferral care. Continuing education programs and referral guidelines must not only emphasize the importance of early referral, but also address the related consequences of CRI to delay the progression of renal disease and avoid complications.

Preemptive kidney transplantation: the advantage and the advantaged

It remains unclear whether preemptive transplantation is beneficial, and if so, who benefits. A total of 38,836 first, kidney-only transplants between 1995 and 1998 were retrospectively studied. A surprising 39% of preemptive transplants were from cadaver donors, and the proportions of cadaver donor transplants that were preemptive changed little, from 7.3% in 1995 to 7.7% in 1998. Preemptive transplants using cadaver donors were more likely among recipients aged 0 to 17 yr versus 18 to 29 yr (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.94 to 3.17), white versus black (OR, 2.33; 95% CI, 2.03 to 2.68), able to work versus unable to work (OR, 1.42; 95% CI, 1.26 to 1.61), covered by private insurance versus Medicare (OR, 4.77; 95% CI, 4.26 to 5.32), or recipients with a college degree versus no college degree (OR, 1.34; 95% CI, 1.17 to 1.54). Preemptive transplants were less likely for Hispanics versus non-Hispanics (OR, 0.57; 95% CI, 0.50 to 0.67), patients with type 2 versus type 1 diabetes (OR, 0.76; 95% CI, 0.61 to 0.96), and for 2 to 5 HLA mismatches compared with 0 HLA mismatches (OR range, 0.77 to 0.82). In adjusted Cox proportional hazards analysis, the relative risk of graft failure for preemptive transplantation was 0.75 (0.67 to 0.84) among 25,758 cadaver donor transplants and 0.73 (0.64 to 0.83) among 13,078 living donor transplants, compared with patients who received a transplant after already being on dialysis. Preemptive transplantation was associated with a reduced risk of death: 0.84 (0.72 to 0.99) for cadaver donor transplants and 0.69 (0.56 to 0.85) for living donor transplants. Thus, preemptive transplantation, which is associated with improved patient and graft survival, is less common among racial minorities, those who have less education, and those who must rely on Medicare for primary payment. Alterations in the payment system, emphasis on early referral, and changes in cadaver kidney allocation could increase the number of patients who benefit from preemptive transplantation.

Savings in dialysis treatment?

The steadily increasing number of dialysis patients prompts considerations on possibilities for budget reductions with maintenance of treatment quality. A literature survey is presented concerning trends of population increase, individual treatment costs, rationing of patient intake, and consequences of delayed progress of renal insufficiency as well as of savings during both the initial and the later phases of regular dialysis therapy. Cost reduction in one area may well induce rising total budgets and influence clinical outcome. A multidisciplinary approach is suggested to obtain answers to several questions: Can the economic burden of the changing patient demography be counterbalanced by a reorganized staff structure? Will early referral, good predialysis control, and incremental dialysis start imply longer survival? Will increased dialysis doses be economically neutralized by less staff requirements, drug consumption, and patient morbidity? Should dialyzer reuse be abandoned? Can pretransplant dialysis periods be reduced or omitted by improved planning?

Consequences of late referral of patients with end-stage renal disease

OBJECTIVES

The aim of the present retrospective single centre study of patients entering renal replacement therapy (RRT), was to evaluate the effects of different referral patterns on morbidity, choice of therapy, and duration of hospitalization in patients with chronic renal failure.

SUBJECTS

A total of 242 patients with chronic renal failure starting their first RRT between 1984 and 1998, were divided into three groups. Group 1 (n=80): RRT started 1984-88, group 2 (n=73): RRT started 1989-93 and group 3 (n=89): RRT started 1994-98. Patients were classified as early referrals (ER) or late referrals (LR) depending on whether they started first RRT more than or less than 3 months after first referral to a nephrologist.

RESULTS

The proportion of LR was 27.3% (21 patients) in group 1, 27.4% (20 patients) in group 2 and 28.1% (25 patients) in group 3. In the ER, 35 patients (14.5%) received a predialytic kidney transplant, none in the LR. Comparing clinical details, the LR's in group 3 were significantly older than ER [median age 72 (53-81) vs. 56 (15-81) years, P < 0.0001], had a lower serum-albumin [median 33.0 (19.0-42.0) vs. 39 (19.0-48.0) g L-1, P < 0.0001], and serum-calcium [median 2.0 (1.4-2.6) vs. 2.3 (1.8-2.7) mmol L-1, P < 0.0001]. The ER had a significantly higher use of antihypertensive drugs, calcitriol, phosphate binders, and bicarbonate. Of the patients starting RRT on haemodialysis, all LR started on a temporary vascular access. About 43% of the ER started on a functioning arteriovenous fistula (P < 0.0001). The duration of hospital stay in connection with start of dialysis was 31 days (7-73) in the LR as compared with 7 (1-59) days in the ER (P < 0.0001).

CONCLUSIONS

We conclude that in our centre, early referral to nephrologist is associated with lower age, a higher likelihood of predialytic transplantation, better metabolic status at start of RRT, a higher proportion starting haemodialysis on a functioning arteriovenous fistula, and a shorter duration of the initial hospital stay. Further research on health care delivery is warranted.

Screening for renal disease using serum creatinine: who are we missing?

BACKGROUND

Appropriate management and timely referral of patients with early renal disease often depend on the identification of renal insufficiency by primary care physicians. Serum creatinine (SCr) levels are frequently used as a screening test for renal dysfunction; however, patients can have significantly decreased glomerular filtration rates (GFR) with normal range SCr values, making the recognition of renal dysfunction more difficult. This study was designed to estimate the prevalence of patients who have significantly reduced GFR as calculated by the Cockcroft-Gault (C-G) formula, but normal-range SCR:

METHODS

The study included 2781 outpatients referred by community physicians to an urban laboratory network for SCr measurement. GFR was estimated using the C-G formula. Patients were grouped according to the concordance of SCr level abnormalities (abnormal >130 micromol/l) with significantly abnormal C-G values (abnormal </=50 ml/min). The C-G value of < or =50 ml/min was chosen to reflect substantial renal impairment in all age groups. A further analysis of historical laboratory data was undertaken to determine if there were previously documented changes in renal function parameters in those patients who had overt renal dysfunction during the study period.

RESULTS

Of the 2781 outpatients referred, 2543 (91.4%) had normal SCr levels. Of these patients, 387/2543 (15.2%) had C-G calculated GFR < or =50 ml/min, representing substantially impaired renal function. Among patients with normal SCr, abnormal C-G values were identified in 47.3% > or =70 years old, 12.6% 60-69 years old, and 1.2% 40-59 years old. Analysis of historical available laboratory data for patients with abnormal SCr and abnormal C-G values showed that 2 years prior to the study period, 72% of this group had abnormal SCr, while 18% had normal SCr with abnormal C-G values, and 10% had normal SCr with normal C-G values.

CONCLUSIONS

This study documents the substantial prevalence of significantly abnormal renal function among patients identified by laboratories as having normal-range SCR: Including calculated estimates of GFR in routine laboratory reporting may help to facilitate the early identification of patients with renal impairment.

[From the first symptoms to terminal renal failure: need for a nephrologic follow-up]

PURPOSE

As patients with chronic renal failure are frequently referred late to nephrologists, we decided to quantify the magnitude of late referral and its consequences.

METHODS

We studied retrospectively an inception cohort of 62 patients starting dialysis (either hemodialysis or continuous ambulatory peritoneal dialysis) during 1993 with a 4-year follow-up.

RESULTS

The mean delay between either first symptoms of renal disease, or first evidence of renal failure and nephrologist referral was 10 years and 3 years 56 days, respectively. About 47% of the patients were referred less than 6 months before starting dialysis, and 27.5% less than 1 month. Blood pressure levels were higher in patients referred less than 6, 3 and 1 month (P < 0.05), as was creatinine concentration in patients referred less than 1 month (P < 0.05). In contrast, plasma calcium was lower for referral less than 6 months (P < 0.05) and 3 months (P < 0.005), as was bicarbonate concentration for referral less than 3 and 1 month (P < 0.05). Initial hospitalisation stay was prolonged (x1.5) for late referral less than 3 months (56.4 +/- 39 days vs 35.9 +/- 33.6 days, P < 0.05) as was 6 months hospitalisation length for referral less than 3 months (x1.6) (52.9 +/- 40.6 days vs 33.2 +/- 28.7 days, P < 0.05) and less than 1 month (x1.8) (61 +/- 45 days vs 33.9 +/- 28.7 days, P < 0.05) and < 1 month (x1.8) (61 +/- 45 days vs 33.9 +/- 28.7 days, P < 0.05). Only 44.1% of patients started hemodialysis with a functioning arteriovenous fistula, and patients requiring temporary access had a 4.4-fold longer initial (60.1 +/- 41.7 days vs 13.6 +/- 11.6 days, P < 0.005) and 6-month (59.6 +/- 39 days vs 13.6 (9.1, P < 0.005) hospitalisation stay. The four-year mortality rate was unaffected by the delayed referral but strongly and independently predicted by age, diabetes and hypoalbuminemia.

CONCLUSION

Early nephrologic referral and timely initiated dialysis decrease morbidity at the start of dialysis and both hospitalisation length and costs.