High Prevalence of Unlabeled Chronic Kidney Disease Among Inpatients at a Tertiary-Care Hospital

An Interdisciplinary Approach to Optimize the Care of Transitioning Adolescents and Young Adults with CKD

Adolescents and young adults (AYAs) with CKD or end-stage kidney disease (ESKD) have unique medical, dental, psychosocial, neurocognitive, and academic needs and require close interdisciplinary collaboration to optimize their care. The etiology of CKD in AYAs is diverse compared to older adults. With their continuously improved survival, AYAs must start preparation for health-care transition (HCT) from pediatric- to adult-focused health care in the pediatric setting and it must continue at the adult-focused setting, given that their brain maturation and self-management skill acquisition occur until their mid-20s. While the growth and physical maturation of most visible body parts occur before 18 years of age, the prefrontal cortex of the brain, where reasoning, impulse control, and other higher executive functions reside, matures around 25 years of age. The HCT process must be monitored using patient- and caregiver-measuring tools to guide interventions. The HCT process becomes more complex when patients and/or caregivers have a language barrier, different cultural beliefs, or lower literacy levels. In this article, we discuss the unique comorbidities of pediatric-onset CKD/ESKD, provide information for a planned HCT preparation, and suggest interdisciplinary coordination as well as cultural and literacy-appropriate activities to achieve optimal patient outcomes.

Prevalence and associated factors of impaired renal function and albuminuria among adult patients admitted to a hospital in Northeast Ethiopia

Background

Chronic kidney disease (CKD) is increasingly common in hospitalized patients and is associated with increased risk for in-hospital morbidity and mortality. However, data regarding the prevalence of CKD in the African hospitalized patient population are limited. We therefore examined the prevalence and associated factors of impaired renal function and albuminuria among adult patients admitted to the internal medicine wards of a hospital in Northeast Ethiopia.

Methods

A cross-sectional study was conducted from January 1 to April 30, 2020 at the inpatient settings of Dessie referral hospital. Data on demographics and medical history were obtained, and serum creatinine and albuminuria were analyzed. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) equation. CKD was defined as impaired eGFR (<60 ml/min/1.73m²) and/or albuminuria. Univariate and multivariable analysis were conducted to determine factors associated with impaired eGFR and albuminuria.

Results

A total of 369 patients were included in this study. The prevalence of impaired eGFR was 19.0% (95%CI: 15.2%–23.2%) and albuminuria was 30.9% (95%CI: 26.3%–35.7%). Overall, 33.9% (95%CI: 29.2%–38.9%) of the patients had some degree of CKD, but only 21.6% (95%CI: 15.1%–29.4%) were aware of their renal disease. In multivariable analysis, older age, a family history of kidney disease, diabetes, hypertension and HIV were independently associated with both impaired eGFR and albuminuria while male gender was independently associated with only albuminuria.

Conclusions

CKD is common in adult patients admitted to the internal medicine wards, but only few patients are aware of their condition. These findings highlight the need for feasible approaches to timely identify kidney disease and raise awareness on the importance of detection and early intervention in the inpatient settings.

Diagnosis Patterns of CKD and Anemia in the Japanese Population

INTRODUCTION

Although early intervention for chronic kidney disease (CKD) and renal anemia are desirable, these conditions are often asymptomatic during their early stages and may be underdiagnosed.

METHODS

We retrospectively analyzed Japanese administrative claims data for general and hospital populations. The data period for the general and hospital data ranged from January 2011 to December 2016 and from April 2008 to July 2017, respectively. CKD stage was determined by estimated glomerular filtration rate (eGFR). Anemia was defined per Japanese guidelines using hemoglobin (Hb) values. The proportion of patients who had eGFR-defined stages G3-G5 CKD without a CKD diagnosis, and Hb-defined anemia without an anemia diagnosis or treatment records, was estimated.

RESULTS

Among 16,779 (general) and 68,161 (hospital) patients, a high proportion of G3 CKD patients did not have a CKD-related diagnosis (general: G3a, 95.0%; G3b, 68.4%; hospital: G3a, 89.2%; G3b, 67.9%); however, some patients were treated with antihypertensives. Among anemic patients, 75.7% (G3a) and 66.7% (G3b) of the general population, and 56.2% (G3a) and 47.5% (G3b) of the hospital population, did not have an anemia-related diagnosis or treatment. CKD and anemia were more likely to be diagnosed in patients with G4 and G5 CKD.

CONCLUSION

A high proportion of G3 CKD patients did not have a CKD-related diagnosis. Likewise, many anemic patients with G3 CKD did not have an anemia-related diagnosis. Despite the lack of a CKD-related diagnosis, some patients received appropriate treatment (e.g., antihypertensives). Further outreach to CKD and anemia patients at earlier stages may be warranted.

Incidence and risk of dialysis therapy within 30 days after contrast enhanced computed tomography in patients coded with chronic kidney disease: a nation-wide, population-based study

Background

Patients with chronic kidney disease (CKD) are considered at risk of contrast-induced acute kidney injury and possible subsequent need for dialysis therapy. Computed tomography (CT) is the most commonly performed examination requiring intravenous iodinated contrast media (ICM) injection. The actual risk of dialysis in CKD patients undergoing CT with ICM remains controversial. Furthermore, it is also uncertain whether these at-risk patients can be identified by means of administrative data. Our study is conducted in order to determine the incidence and risk of dialysis within 30 days after undergoing contrast enhanced CT in CKD coded patients.

Methods

This longitudinal, nation-wide, populated-based study is carried out by analyzing the Taiwan National Health Insurance Research Database retrospectively. Patients coded under the diagnosis of CKD who underwent CT are identified within randomly selected one million subjects of the database. From January 2012 to December 2013, 487 patients had undergone CT with ICM. A total of 924 patients who underwent CT without ICM are selected as the control group. Patients with advanced CKD or intensive care unit (ICU) admissions are assigned to the subgroups for analysis. The primary outcome is measured by dialysis events within 30 days after undergoing CT scans. The cumulative incidence is assessed by the Kaplan–Meier method and log-rank test. The risk of 30-day dialysis relative to the control group is analyzed by the Cox proportional hazards model after adjusting for age, sex, and baseline comorbidities.

Results

The numbers and percentages of dialysis events within 30 days after undergoing CT scans are 20 (4.1%) in the CT with ICM group and 66 (7.1%) in the CT without ICM group (p = 0.03). However, the adjusted hazard ratio (aHR) for 30-day dialysis was 0.84 (95% CI [0.46–1.54], p = 0.57), which is statistically non-significant. In both advanced CKD and ICU admission subgroups, there are also no significant differences in 30-day dialysis risks with the aHR of 1.12 (95% CI [0.38–3.33], p = 0.83) and 0.95 (95% CI [0.44–2.05], p = 0.90), respectively.

Conclusions

Within 30 days of receiving contrast-enhanced CT scans, 4.1% of CKD coded patients required dialysis, which appear to be lower compared with subjects who received non-contrast CT scans. However, no statistically significant difference is observed after adjustments are made for other baseline conditions. Thereby, the application of administrative data to identify patients with CKD cannot be viewed as a risk factor for the necessity to undergo dialysis within 30 days of receiving contrast-enhanced CT scans.

Lab-based and diagnosis-based chronic kidney disease recognition and staging concordance

BACKGROUND

Chronic kidney disease (CKD) is often under-recognized and poorly documented via diagnoses, but the extent of under-recognition is not well understood among Medicare beneficiaries. The current study used claims-based diagnosis and lab data to examine patient factors associated with clinically recognized CKD and CKD stage concordance between claims- and lab-based sources in a cohort of Medicare beneficiaries.

METHODS

In a cohort of fee-for-service (FFS) beneficiaries with CKD based on 2011 labs, we examined the proportion with clinically recognized CKD via diagnoses and factors associated with clinical recognition in logistic regression. In the subset of beneficiaries with CKD stage identified from both labs and diagnoses, we examined concordance in CKD stage from both sources, and factors independently associated with CKD stage concordance in logistic regression.

RESULTS

Among the subset of 206,036 beneficiaries with lab-based CKD, only 11.8% (n = 24,286) had clinically recognized CKD via diagnoses. Clinical recognition was more likely for beneficiaries who had higher CKD stages, were non-elderly, were Hispanic or non-Hispanic Black, lived in core metropolitan areas, had multiple chronic conditions or outpatient visits in 2010, or saw a nephrologist. In the subset of 18,749 beneficiaries with CKD stage identified from both labs and diagnoses, 70.0% had concordant CKD stage, which was more likely if beneficiaries were older adults, male, lived in micropolitan areas instead of non-core areas, or saw a nephrologist.

CONCLUSIONS

There is significant under-diagnosis of CKD in Medicare FFS beneficiaries, which can be addressed with the availability of lab results.

Proteinuria impacts patient survival differentially based on clinical setting: A retrospective cross-sectional analysis of cohorts from a single health system: Retrospective cohort study

Background

Chronic kidney disease (CKD) staging is improved by adding proteinuria to glomerular filtration rate (GFR). While proteinuria independently predicts CKD progression and mortality, the clinical setting of proteinuria determination has not been well-studied previously. The objective of our study is to determine whether clinical setting differentially impacts survival outcomes.

Methods

Kaplan-Meier and Cox proportional hazards analyses of overall survival were performed retrospectively for cohorts of outpatients (n = 22,918), emergency patients (n = 16,861), and inpatients (n = 12,304) subjected to urinalysis (UA) at a single health system in 2010. GFR (G1-G5) and proteinuria (A1:<30 mg, A2:30–300 mg, A3:>300 mg) were classified under Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

Results

GFR and proteinuria levels varied more in inpatients than in emergency and outpatients. For each clinical population, survival significantly decreased with increasing proteinuria (A1>A2>A3, p < 0.05 for each comparison). The effect of proteinuria on survival differed by clinical setting, with statistical differences in all categories other than A3 in outpatients and emergency patients (p = 0.98). The strongest predictors of mortality were cancer diagnosis (HR: 3.07, p < 0.0001) and very-high KDIGO classification (HR: 2.01, p < 0.0001). Limitations include the retrospective observational study design and single health system analysis.

Conclusions

The value of UA to screen for proteinuria in each clinical setting is evident, but the impact of A2 and A3 level proteinuria on survival varies depending on the clinical scenario in which the determination was made. The clinical setting of proteinuria measurement should be factored into both patient care and clinical research activities.

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Proteinuria and GFR independently predict survival in inpatients, ED and outpatients.

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The effect of proteinuria on survival differs by clinical setting.

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Hospitalized patients have lower survival rates than emergency and outpatients.

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Clinical setting of proteinuria should be considered in patient care and research.

Prevalence and factors associated with chronic kidney disease among medical inpatients at the Kenyatta National Hospital, Kenya, 2018: a cross-sectional study

INTRODUCTION

The burden of chronic kidney disease (CKD) is increasing worldwide. Few studies in low and low-middle income countries have estimated the prevalence of CKD. We aimed to estimate prevalence and factors associated with CKD among medical inpatients at the largest referral hospital in Kenya.

METHODS

We conducted a cross-sectional study among medical inpatients at the Kenyatta National Hospital. We used systematic sampling and collected demographic information, behavioural risk factors, medical history, underlying conditions, laboratory and imaging workup using a structured questionnaire. We estimated glomerular filtration rate (GFR) in ml/min/1.73m2 classified into 5 stages; G1 (≥ 90), G2 (60-89), G3a (45-59), G3b (30-44), G4 (15-29) and G5 (<15, or treated by dialysis/renal transplant). Ethical approval was obtained from Kenyatta National Hospital-University of Nairobi Ethics and Research Committee (KNH-UoN ERC), approval number P510/09/2017. We estimated prevalence of CKD and used logistic regression to determine factors independently associated with CKD diagnosis.

RESULTS

We interviewed 306 inpatients; median age 40.0 years (IQR 24.0), 162 (52.9%) were male, 155 (50.7%) rural residents. CKD prevalence was 118 patients (38.6%, 95% CI 33.3-44.1); median age 42.5 years (IQR 28.0), 74 (62.7%) were male, 64 (54.2%) rural residents. Respondents with CKD were older than those without (difference 4.4 years, 95% CI 3.7-8.4 years, P = 0.032). Fifty-six (47.5%) of the patients had either stage G1 or G2, 17 (14.4%) had end-stage renal disease; 64 (54.2%) had haemoglobin below 10g/dl while 33 (28.0%) had sodium levels below 135 mmol/l. ). History of unexplained anaemia (aOR 1.80, 95% CI 1.02-3.19), proteinuria (aOR 5.16, 95% CI 2.09-12.74), hematuria (aOR 7.68, 95% CI 2.37-24.86); hypertension (aOR 2.71, 95% CI 1.53-4.80) and herbal medications use (aOR 1.97, 95% CI 1.07-3.64) were independently associated with CKD.

CONCLUSION

Burden of CKD was high among this inpatient population. Haematuria and proteinuria can aid CKD diagnosis. Public awareness on health hazards of herbal medication use is necessary.

Patient Awareness, Prevalence, and Risk Factors of Chronic Kidney Disease among Diabetes Mellitus and Hypertensive Patients at Jimma University Medical Center, Ethiopia

Background

There is an alarming rise of chronic kidney disease (CKD) prevalence globally, which is associated with significant morbidity and mortality necessitating special attention as one of the major public health problems. The burden of CKD disproportionately impacts low-income countries like Ethiopia where hypertension and diabetes mellitus, the two most important risk factors for CKD growth rate, are greatest.

Objective

The aim of this study is to assess patient awareness, prevalence, and risk factors of chronic kidney disease among hypertensive and diabetes mellitus patients.

Methods

Hospital based cross-sectional study design was conducted at Jimma University Medical Center among adult (≥18 years) hypertensive and diabetes mellitus patients. Informed written consent was obtained from each participant and data was collected by interview and chart review; blood and urine samples were collected for CKD screening. Glomerular filtration rate (GFR) was estimated from serum creatinine using CKD epidemiology collaboration (CKD-EPI) equation, and CKD was defined using estimated GFR (e-GFR) and albuminuria. Multivariate logistic regression was used to identify independent predictors of CKD and p-value <0.05 considered statistically significant.

Result

Mean (±SD=standard deviation) age of participants was 54.81 ± 12.45 years and 110 (52.9%) of them were male. Only 59 (28.4%) of the participants had awareness about CKD and its risk factors. The prevalence of CKD was 26% (95% CI; 20.3%-31.8%). Factors associated with chronic kidney disease were uncontrolled blood pressure (adjusted odds ratio (AOR)=2.22,95% CI=1.01-4.76), fasting blood sugar ≥ 150 mg/dl, (AOR=3.70,95% CI=1.75-7.69), angiotensin converting enzyme inhibitors (ACEIs) nonusers, (AOR=4.35 ,95% CI=1.96-10.0), poor knowledge of CKD (AOR=3.69, 95% CI=1.48-9.20), and long duration of hypertension (AOR=4.55, 95%CI=1.72-11.11).

Conclusion

Our study found out low level of patient awareness and high prevalence of CKD. The predictors of CKD were uncontrolled blood pressure, fasting blood sugar> 150 mg/dl, long duration of hypertension, ACEIs nonusers, and poor knowledge about CKD.

Health Literacy Not Associated with Chronic Kidney Disease Awareness

Background:

Patient awareness of their chronic kidney disease (CKD) and health literacy (HL) are both important for adherence to therapies that slow CKD progression and to reduce risk of complications. Little is known about the association between HL and CKD awareness.

Objective:

We sought to determine if patient HL is associated with CKD awareness.

Methods:

We conducted a cross-sectional study of general medicine inpatients at an urban academic medical center discharged between June 2011 and July 2013 with CKD, defined as having at least one CKD International Classification of Diseases, ninth revision code (585.0–585.9), among their first 20 admission diagnoses. Logistic regression was used to analyze the influence of HL, demographic, clinical, and health care use covariates on the likelihood of patients' CKD awareness. Our primary outcome was patient awareness of their CKD, defined as correct patient self-report of “kidney problems.” We used the Brief Health Literacy Screen, a three-item verbal questionnaire, to assess HL.

Key Results:

Among 1,308 patients with CKD, awareness of CKD was 33%, and 48% had adequate HL. However, CKD awareness was not associated with HL even among patients with stage 4 or 5 CKD. In multivariable logistic regression, greater awareness was associated with being a woman, younger than age 50 years, married, White, having hypertension, and having a higher CKD stage (all p < .05). In stratified analyses, patients with hypertension had greater CKD awareness, regardless of HL or diabetes status (p < .05).

Conclusions:

Among hospitalized patients with CKD, both CKD awareness and HL are low and inadequate. Surprisingly, patients' knowledge of their CKD diagnosis was not related to patients' HL. Patients with hypertension who young, white, or married may be receiving or retaining more education related to CKD. More work is needed on how to effectively communicate CKD diagnosis to prevent widening health disparities. [Health Literacy Research and Practice. 2017;1(3):e117–e127.]

Plain Language Summary:

We studied whether patients with low health literacy also had low awareness of their chronic kidney disease (CKD). Hospitalized patients with CKD were asked three questions about their health literacy and whether they had “kidney problems.” Overall CKD awareness and health literacy were low, but a low score on one did not predict a low score on the other.

Nephrology care prior to end-stage renal disease and outcomes among new ESRD patients in the USA

Background

Longer nephrology care before end-stage renal disease (ESRD) has been linked with better outcomes.

Methods

We investigated whether longer pre-end-stage renal disease (ESRD) nephrology care was associated with lower mortality at both the patient and state levels among 443 761 incident ESRD patients identified in the USA between 2006 and 2010.

Results

Overall, 33% of new ESRD patients had received no prior nephrology care, while 28% had received care for >12 months. At the patient level, predictors of >12 months of nephrology care included having health insurance, white race, younger age, diabetes, hypertension and US region. Longer pre-ESRD nephrology care was associated with lower first-year mortality (adjusted hazard ratio = 0.58 for >12 months versus no care; 95% confidence interval 0.57–0.59), higher albumin and hemoglobin, choice of peritoneal dialysis and native fistula and discussion of transplantation options. Living in a state with a 10% higher proportion of patients receiving >12 months of pre-ESRD care was associated with a 9.3% lower relative mortality rate, standardized for case mix (R² = 0.47; P < 0.001).

Conclusions

This study represents the largest cohort of incident ESRD patients to date. Although we did not follow patients before ESRD onset, our findings, both at the individual patient and state levels, reflect the importance of early nephrology care among those with chronic kidney disease.

Prevalence of chronic kidney disease among individuals with diabetes in the SUPREME-DM Project, 2005-2011

AIMS

Diabetes is a leading cause of chronic kidney disease (CKD). Different methods of CKD ascertainment may impact prevalence estimates. We used data from 11 integrated health systems in the United States to estimate CKD prevalence in adults with diabetes (2005-2011), and compare the effect of different ascertainment methods on prevalence estimates.

METHODS

We used the SUPREME-DM DataLink (n = 879,312) to estimate annual CKD prevalence. Methods of CKD ascertainment included: diagnosis codes alone, impaired estimated glomerular filtration rate (eGFR) alone (eGFR < 60 mL/min/1.73 m(2)), albuminuria alone (spot urine albumin creatinine ratio > 30 mg/g or equivalent), and combinations of these approaches.

RESULTS

CKD prevalence was 20.0% using diagnosis codes, 17.7% using impaired eGFR, 11.9% using albuminuria, and 32.7% when one or more method suggested CKD. The criteria had poor concordance. After age- and sex-standardization to the 2010 U.S. Census population, prevalence using diagnosis codes increased from 10.7% in 2005 to 14.3% in 2011 (P < 0.001). The prevalence using eGFR decreased from 9.7% in 2005 to 8.6% in 2011 (P < 0.001).

CONCLUSIONS

Our data indicate that CKD prevalence and prevalence trends differ according to the CKD ascertainment method, highlighting the necessity for multiple sources of data to accurately estimate and track CKD prevalence.

Is routine hospital episode data sufficient for identifying individuals with chronic kidney disease? A comparison study with laboratory data

Internationally, investment in the availability of routine health care data for improving health, health surveillance and health care is increasing. We assessed the validity of hospital episode data for identifying individuals with chronic kidney disease compared to biochemistry data in a large population-based cohort, the Grampian Laboratory Outcomes, Morbidity and Mortality Study-II (n = 70,435). Grampian Laboratory Outcomes, Morbidity and Mortality Study-II links hospital episode data to biochemistry data for all adults in a health region with impaired kidney function and random samples of individuals with normal and unmeasured kidney function in 2003. We compared identification of individuals with chronic kidney disease by hospital episode data (based on International Classification of Diseases-10 codes) to the reference standard of biochemistry data (at least two estimated glomerular filtration rates <60 mL/min/1.73 m(2) at least 90 days apart). Hospital episode data, compared to biochemistry data, identified a lower prevalence of chronic kidney disease and had low sensitivity (<10%) but high specificity (>97%). Using routine health care data from multiple sources offers the best opportunity to identify individuals with chronic kidney disease.

Identification of incident CKD stage 3 in research studies

BACKGROUND

In epidemiologic research, incident chronic kidney disease (CKD) commonly is determined by laboratory tests performed at planned study visits. Given the morbidity and mortality associated with CKD, persons with incident disease may be less likely to attend scheduled visits, affecting observed associations. The objective of this study was to quantify loss to follow-up by CKD status and determine whether supplementation with diagnostic code data improves capture of incident CKD.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

11,560 participants in the Atherosclerosis Risk in Communities (ARIC) Study underwent continuous surveillance for hospitalizations and death from baseline visit (1996-1999) to follow-up visit (2011-2013). A subset of hospitalizations in Washington County, MD, was used in diagnostic code validation (n=2,540).

PREDICTOR

Baseline demographics and comorbid conditions.

OUTCOMES

Incident CKD stage 3 ascertained by follow-up visit (visit-based definition) or hospitalization surveillance (hospitalization-based definition).

MEASUREMENTS

Visit-based definition: ≥25% decline from baseline estimated glomerular filtration rate to <60 mL/min/1.73 m2 at follow-up visit; hospitalization-based definition: hospitalization CKD diagnostic code.

RESULTS

Of 11,560 participants, 5,951 attended the follow-up visit and 9,264 were hospitalized. Never-hospitalized participants were younger, more often female, and had fewer comorbid conditions; 73.5% attended the follow-up visit. Incident CKD stage 3 occurred in 1,172 participants by the visit-based definition (251 were never hospitalized) and 1,078 participants by the hospitalization-based definition (237 attended the follow-up study visit). Sensitivity of the hospitalization-based CKD definition was 35.5% (95% CI, 31.6%-39.7%); specificity was 95.7% (95% CI, 94.2%-96.8%). Sensitivity was higher with later time period, older participant age, and baseline prevalent diabetes and CKD.

LIMITATIONS

A subset of hospitalizations was used for validation; 15-year gap between study visits.

CONCLUSIONS

The sensitivity of diagnostic code-identified CKD is low and varies by certain factors; however, supplementing a visit-based definition with hospitalization information can increase disease identification during periods of follow-up without study visits.

Knowledge, attitudes, and practices towards prevention and early detection of chronic kidney disease

OBJECTIVE

To describe the knowledge, attitudes and practices of Jordanian patients with chronic illnesses towards prevention and early detection of chronic kidney disease.

BACKGROUND

Patients with chronic illnesses such as hypertension and diabetes need to adopt healthy attitudes and practices and gain knowledge regarding prevention and early detection of kidney disease to decrease the prevalence of dialysis-related complications and costs.

METHODS

A total of 740 patients were recruited from out-patients clinics in Jordan. Knowledge, attitudes and practices about kidney disease prevention and early detection were measured using the Chronic Kidney Disease Screening Index which was developed by the researcher and tested for validity and reliability.

RESULTS

The results revealed that most of the participants have knowledge about kidney disease; however, half of them had wrong information related to signs and symptoms of chronic kidney disease. The majority of the participants were not aware about the importance of discovering health problems at early stages.

CONCLUSION AND IMPLICATIONS

Improvement in population understanding about chronic kidney disease is needed to advance their awareness and practices to make appropriate decisions towards health promotion and better quality of life.

IMPLICATION FOR POLICY DEVELOPMENT

Nurses need to be involved in development of protocols for screening and intervention programmes, taking into consideration the cultural issues and the financial status of individuals at risk for kidney disease. Governments should adopt a public health policy for chronic kidney disease that supports programmes for screening and programmes for improving public awareness for kidney disease prevention.

A pilot trial of a computerized renal template note to improve resident knowledge and documentation of kidney disease

BACKGROUND

Kidney disease is under-documented in physician notes. The use of template-guided notes may improve physician recognition of kidney disease early in training.

OBJECTIVE

The objective of this study was to determine whether a computerized inpatient renal template note with clinical decision support improves resident knowledge and documentation of kidney disease.

METHODS

In this prospective study, first year medical residents were encouraged to use the renal template note for documentation over a one-month period. The renal template note included an option for classification of acute kidney injury (AKI) and chronic kidney disease (CKD) categories with a link to standard classifications. Pre- and post-knowledge of AKI and CKD categories was tested with a quiz and surveys of resident experience with the intervention were conducted. Appropriate AKI and/or CKD classification was determined in 100 renal template notes and 112 comparable historical internal medicine resident progress notes from approximately one year prior.

RESULTS

2,435 inpatient encounters amongst 15 residents who participated were documented using the renal template note. A significantly higher percent of residents correctly staged earlier stage CKD (CKD3) using the renal template note compared to historical notes (9/46 vs. 0/33, p<0.01). Documentation of AKI and more advanced CKD stages (CKD4 and 5) did not improve. Knowledge based on quiz scores increased modestly but was not significant. The renal template note was well received by residents and was perceived as helping improve knowledge and documentation of kidney disease.

CONCLUSION

The renal template note significantly improved staging of earlier stage CKD (CKD3) with a modest but non-significant improvement in resident knowledge. Given the importance of early recognition and treatment of CKD, future studies should focus on teaching early recognition using template notes with supplemental educational interventions.

Awareness of chronic kidney disease in Austria: a frequently under-recognized clinical picture

BACKGROUND

The prevalence of chronic kidney disease (CKD) is rising at an alarming rate, thus presenting a substantial burden for the patient as an individual and-because of the enormous treatment costs-for society as a whole. Early diagnosis and therapy could slow disease progression and reduce the prevalence of cost-intensive end stage renal disease. The aim of this study was to determine the accuracy of diagnosis of CKD in acute patients presenting at an internal ward.

METHODS

Routine laboratory parameters of kidney function of 238 inpatients were retrospectively evaluated to determine the prevalence of CKD, defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m(2). Those results were compared with the actual documentation of the ICD-10 diagnosis CKD in the discharge reports of the respective patients.

RESULTS

Of 238 patients, 228 patients were included in the analysis. The overall median (range) eGFR was 60.7 (10.4-171.9) mL/min/1.73 m(2), with no gender-specific difference. Of patients, 49.6 % (n = 113) were retrospectively diagnosed with CKD stage 3 or higher. However, the review of the discharge reports found correct diagnosis of CKD in only 38.1 % (n = 43) of these patients.

CONCLUSIONS

The present analysis shows that CKD remains frequently unrecognized, even in a hospital setting. This could have dramatic implications on the care, treatment and prevention of CKD and associated complications.

Evolving practice patterns for the management of small renal masses in the USA

What's known on the subject? and What does the study add? Treatment options for small renal masses include radical nephrectomy (RN), partial nephrectomy (PN), ablation, and surveillance. PN provides equivalent oncological as RN for small tumours, but long-term outcomes for ablation and surveillance are poorly defined. Due to changing techniques and technology, treatment patterns for small renal masses are rapidly developing. Prior studies had analysed utilisation trends for PN and RN to 2006, revealing a relative rise in the rate of PN. However, overall treatment trends including surveillance and ablation had not been studied using a population-based cohort. It has become increasingly clear that RN is associated with greater renal and cardiovascular deterioration than nephron-sparing treatments. Thus, it is important to understand current population-based practice patterns for the treatment of small renal masses to assess whether practitioners are adhering to ever-changing principles in this field. The present study provides up-to-date treatment trends in the USA using a large population-based cohort.

OBJECTIVE

To describe the changing practice patterns in the management of small renal masses, including the use of surveillance and ablative techniques.

PATIENTS AND METHODS

All patients in the Surveillance, Epidemiology and End Results (SEER) registry treated for renal masses of ≤7 cm in diameter, from 1998 to 2008, were included for analysis. Annual trends in the use of surveillance, ablation, partial nephrectomy (PN), and radical nephrectomy (RN) were calculated. Multinomial logistic regression was used to determine the association of demographic and clinical characteristics with treatment method.

RESULTS

In all, 48 148 patients from 17 registry sites with a mean age of 63.4 years were included for analysis. Between 1998 and 2008, for masses of <2 cm and 2.1-4 cm, there was a dramatic increase in the proportion of patients undergoing PN (31% vs 50%, 16% vs 33%, respectively) and ablation (1% vs 11%, 2% vs 9%, respectively). In multivariable analysis, later year of diagnosis, male gender, being married, clinically localised disease, and smaller tumours were associated with increased use of PN vs RN. Later year of diagnosis, male gender, being unmarried, smaller tumour, and the presence of bilateral masses were associated with increased use of ablation and surveillance vs RN.

CONCLUSIONS

PN is now used in half of all patients with the smallest renal masses, and its use continues to increase over time. Ablation and surveillance are less common overall, but there is increased usage over time in select populations.

Validation of CKD and related conditions in existing data sets: A systematic review

BACKGROUND

Accurate classification of individuals with kidney disease is vital to research and public health efforts aimed at improving health outcomes. Our objective is to identify and synthesize published literature evaluating the accuracy of existing data sources related to kidney disease.

STUDY DESIGN

A systematic review of studies seeking to validate the accuracy of the underlying data relevant to kidney disease.

SETTING & POPULATION

US-based and international studies covering a wide range of both outpatient and inpatient study populations.

SELECTION CRITERIA FOR STUDIES

Any English-language study investigating the prevalence or cause of kidney disease, existence of comorbid conditions, or cause of death in patients with chronic kidney disease (CKD). All definitions and stages of CKD, including end-stage renal disease (ESRD), were accepted.

INDEX TESTS

Presence of a kidney disease-related variable in existing data sets, including administrative data sets and disease registries.

REFERENCE TESTS

Presence of a kidney disease-related variable defined using laboratory criteria or medical record review.

RESULTS

30 studies were identified. Most studies investigated the accuracy of kidney disease reporting, comparing coded renal disease with that defined using estimated glomerular filtration rate. The sensitivity of coded renal disease varied widely (0.08-0.83). Specificity was higher, with all studies reporting values ≥0.90. Studies evaluating the cause of CKD, comorbid conditions, and cause of death in patients with CKD used ESRD or transplant populations exclusively, and accuracy was highly variable compared with ESRD registry data.

LIMITATIONS

Only English-language studies were evaluated.

CONCLUSIONS

Given the heterogeneous results of validation studies, a variety of attributes of existing data sources, including the accuracy of individual data items within these sources, should be considered carefully before use in research, quality improvement, and public health efforts.