Effectiveness and current status of multidisciplinary care for patients with chronic kidney disease in Japan: a nationwide multicenter cohort study

Background

Multidisciplinary care is well established in clinical practice, but its effectiveness in patients with chronic kidney disease (CKD) remains unclear. The aim of this study was to determine whether multidisciplinary care could help to avoid worsening kidney function in patients with CKD.

Methods

This nationwide study had a multicenter retrospective observational design and included 3015 Japanese patients with CKD stage 3–5 who received multidisciplinary care. We assessed the annual decrease in estimated glomerular filtration rate (ΔeGFR) and urinary protein in the 12 months before and 24 months after the start of multidisciplinary care. All-cause mortality and initiation of renal replacement therapy were investigated according to baseline characteristics.

Results

Most of the patients had CKD stage 3b or higher and a median eGFR of 23.5 mL/min/1.73 m2. The multidisciplinary care teams consisted of health care professionals from an average of four disciplines. ΔeGFR was significantly smaller at 6, 12, and 24 months after initiation of multidisciplinary care (all P < 0.0001), regardless of the primary cause of CKD and its stage when multidisciplinary intervention was started. Urinary protein level also decreased after initiation of multidisciplinary care. After a median follow-up of 2.9 years, 149 patients had died and 727 had started renal replacement therapy.

Conclusion

Multidisciplinary care may significantly slow the decline in eGFR in patients with CKD and might be effective regardless of the primary disease, including in its earlier stages. Multidisciplinary care is recommended for patients with CKD stage 3–5.

Trial registration

UMIN00004999.

Trends in nephrology referral patterns for patients with chronic kidney disease: Retrospective cohort study

Introduction

Information on early, guideline discordant referrals in nephrology is limited. Our objective was to investigate trends in referral patterns to nephrology for patients with chronic kidney disease (CKD).

Methods

Retrospective cohort study of adults with ≥1 visits to a nephrologist from primary care with ≥1 serum creatinine and/or urine protein measurement <180 days before index nephrology visit, from 2006 and 2019 in Alberta, Canada. Guideline discordant referrals were those that did not meet ≥1 of: Estimated glomerular filtration rate (eGFR) ˂ 30 mL/min/1.73m², persistent albuminuria (ACR ≥ 300 mg/g, PCR ≥ 500 mg/g, or Udip ≥ 2+), or progressive and persistent decline in eGFR until index nephrology visit (≥ 5 mL/min/1.73m²).

Results

Of 69,372 patients with CKD, 28,518 (41%) were referred in a guideline concordant manner. The overall rate of first outpatient visits to nephrology increased from 2006 to 2019, although guideline discordant referrals showed a greater increase (trend 21.9 per million population/year, 95% confidence interval 4.3, 39.4) versus guideline concordant referrals (trend 12.4 per million population/year, 95% confidence interval 5.7, 19.0). The guideline concordant cohort were more likely to be on renin-angiotensin system blockers or beta blockers (hazard ratio 1.14, 95% confidence interval 1.12, 1.16), and had a higher risk of CKD progression (hazard ratio 1.09, 95% confidence interval 1.06, 1.13), kidney failure (hazard ratio 7.65, 95% confidence interval 6.83, 8.56), cardiovascular event (hazard ratio 1.40, 95% confidence interval 1.35,1.45) and mortality (hazard ratio 1.58, 95% confidence interval 1.52, 1.63).

Conclusions

A significant proportion nephrology referrals from primary care were not consistent with current guideline-recommended criteria for referral. Further work is needed to identify quality improvement initiatives aimed at enhancing referral patterns of patients with CKD.

The influence of multidisciplinary team clinic on the prognosis of patients with chronic kidney disease

Chronic kidney disease (CKD) seriously affects the quality of life and survival time of patients, and even affects social and national economic development. In China, how to effectively control the disease process of CKD outpatients has not been determined. A retrospective analysis was made to 100 patients with CKD. Fifty patients treated with traditional clinical treatment were in the control group, and the other fifty patients treated with multidisciplinary team (MDT) clinical treatment were in the MDT group. The prognosis of the two groups after treatment was compared, including glomerular filtration rate (GFR), number of renal replacement treatments, and mortality, to evaluate the actual effect of MDT clinic. CKD patients in the MDT group received the MDT clinic for 24 months. There was no significant difference between GFR and serum creatinine level before treatment, and the quality of life was significantly higher than before. In the control group, the GFR declined more dramatically, the serum creatinine level was higher, and the quality of life was lower than before (P < 0.05). The frequency of renal replacement therapy and mortality in the MDT group were significantly lower than those in the control group (P < 0.05). MDT clinic can effectively improve the prognosis of patients with CKD, delay kidney disease progression, and reduce mortality.

Healthcare professionals' perspectives on facilitators of and barriers to CKD management in primary care: a qualitative study in Singapore clinics

INTRODUCTION

The burden of chronic kidney disease (CKD) is rising globally including in Singapore. Primary care is the first point of contact for most patients with early stages of CKD. However, several barriers to optimal CKD management exist. Knowing healthcare professionals' (HCPs) perspectives is important to understand how best to strengthen CKD services in the primary care setting. Integrating a theory-based framework, we explored HCPs' perspectives on the facilitators of and barriers to CKD management in primary care clinics in Singapore.

METHODS

In-depth interviews were conducted on a purposive sample of 20 HCPs including 13 physicians, 2 nurses and 1 pharmacist from three public primary care polyclinics, and 4 nephrologists from one referral hospital. Interviews were audio recorded, transcribed verbatim and thematically analyzed underpinned by the Theoretical Domains Framework (TDF) version 2.

RESULTS

Numerous facilitators of and barriers to CKD management identified. HCPs perceived insufficient attention is given to CKD in primary care and highlighted several barriers including knowledge and practice gaps, ineffective CKD diagnosis disclosure, limitations in decision-making for nephrology referrals, consultation time, suboptimal care coordination, and lack of CKD awareness and self-management skills among patients. Nevertheless, intensive CKD training of primary care physicians, structured CKD-care pathways, multidisciplinary team-based care, and prioritizing nephrology referrals with risk-based assessment were key facilitators. Participants underscored the importance of improving awareness and self-management skills among patients. Primary care providers expressed willingness to manage early-stage CKD as a collaborative care model with nephrologists. Our findings provide valuable insights to design targeted interventions to enhance CKD management in primary care in Singapore that may be relevant to other countries.

CONCLUSIONS

The are several roadblocks to improving CKD management in primary care settings warranting urgent attention. Foremost, CKD deserves greater priority from HCPs and health planners. Multipronged approaches should urgently address gaps in care coordination, patient-physician communication, and knowledge. Strategies could focus on intensive CKD-oriented training for primary care physicians and building novel team-based care models integrating structured CKD management, risk-based nephrology referrals coupled with education and motivational counseling for patients. Such concerted efforts are likely to improve outcomes of patients with CKD and reduce the ESKD burden.

Efficacy and safety of a low-sodium diet and spironolactone in patients with stage 1-3a chronic kidney disease: a pilot study

Background

Excessive salt intake is associated with the deterioration of chronic kidney disease (CKD). Aldosterone is also known as an independent risk factor for kidney injury. Dietary sodium intake acts as a main stimulator in aldosterone-mediated kidney injury. Hence, this study aimed to further investigate the renal protective effects and safety of a low-sodium diet in combination with spironolactone (SPL) in stage 1-3a CKD.

Methods

This single-center, SPL-blinded randomized controlled trial recruited patients with stage 1-3a CKD, randomized into three groups, low-sodium (3 g/d salt) + placebo, medium-sodium (5 g/d salt) + SPL, and low-sodium (3 g/d salt) + SPL. Patients received 12 weeks of intervention. The primary and secondary endpoints were 24-h urine protein and estimated glomerular filtration rate (eGFR) at the end of the intervention, respectively.

Results

A total of 74 patients were analyzed eventually. Significantly decreased 24-h urine protein was found in all three groups, from 0.37 to 0.23 g/d (P = 0.004) in the low-sodium+placebo group, from 0.44 to 0.29 g/d (P = 0.020) in the medium-sodium+SPL group, and from 0.35 to 0.31 g/d (P = 0.013) in the low-sodium +SPL group. There were no significant differences among the three groups in 24-h urine protein amount change after intervention from pre-treatment values (P = 0.760, ITT set). The results of the 24-h urine protein by using PP set analysis was similar to the ITT set. No significant differences in eGFR, nutritional, metabolic, inflammatory, and other biomarkers were observed across all three groups (P > 0.05). No safety signal was observed.

Conclusion

No additional benefit was observed when SPL was prescribed to patients already on a low-sodium diet (3.0 g/d). Still, small doses of SPL may benefit patients with poor sodium restriction. A combination of short-term low-dose SPL and ARB is safe for patients with stage 1-3a CKD, but blood potassium must be regularly monitored.

Trial registration

Name of the registry: Chinese clinical trial registry.

Trial registration number: ChiCTR1900026991.

Date of registration: Retrospectively registered 28 October 2019.

URL of trial registry record: http://www.chictr.org.cn/searchproj.aspx?title=&officialname=&subjectid=&secondaryid=&applier=&studyleader=ðicalcommitteesanction=&spo

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02711-z.

Role of Nanotechnology and Their Perspectives in the Treatment of Kidney Diseases

Nanoparticles (NPs) are differing in particle size, charge, shape, and compatibility of targeting ligands, which are linked to improved pharmacologic characteristics, targetability, and bioavailability. Researchers are now tasked with developing a solution for enhanced renal treatment that is free of side effects and delivers the medicine to the active spot. A growing number of nano-based medication delivery devices are being used to treat renal disorders. Kidney disease management and treatment are currently causing a substantial global burden. Renal problems are multistep processes involving the accumulation of a wide range of molecular and genetic alterations that have been related to a variety of kidney diseases. Renal filtration is a key channel for drug elimination in the kidney, as well as a burgeoning topic of nanomedicine. Although the use of nanotechnology in the treatment of renal illnesses is still in its early phases, it offers a lot of potentials. In this review, we summarized the properties of the kidney and characteristics of drug delivery systems, which affect a drug’s ability should focus on the kidney and highlight the possibilities, problems, and opportunities.

Safe and appropriate use of diclofenac in chronic kidney disease: An Indian perspective

Pain is most common symptom associated with progressive disorder, chronic kidney disease (CKD), and is usually undertreated during the early stages of CKD. So, present review was conducted to evaluate the challenges for the management of pain in CKD patients and addresses the scope for considering Diclofenac as suitable alternative for pain management in CKD patient. The database PubMed and Google Scholar were searched from 1970 to Dec 2020 for literature published in English and all studies, review articles that examined the use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) in pain management in CKD patients were included. Literatures revealed that there is a considerable challenge in appropriate management of pain in CKD patients include understanding the altered pharmacokinetics and pharmacodynamics of analgesics in CKD patients and the risk of acute interstitial nephritis. The shorter duration of analgesics is acceptable and considered to pose a low risk of acute interstitial nephritis in patients. Considering that Diclofenac has a shorter half-life and high efficacy, it may be well tolerated in patients with CKD. The acceptance of Diclofenac is partly attributed to being a potent COX-2 inhibitor with the lowest IC50 and its rapid onset of action at lowest effective dose. In conclusion, diclofenac may be well tolerated in patients of renal impairment when used at lowest effective dose for shortest dose duration. Diclofenac is worthy of consideration in mild to moderate cases of CKD. For effective pain management, it is vital to evaluate the tolerability and efficacy of the available analgesics critically.

Poverty, Racism, and the Public Health Crisis in America

The purpose of this article is to discuss poverty as a multidimensional factor influencing health. We will also explicate how racism contributes to and perpetuates the economic and financial inequality that diminishes prospects for population health improvement among marginalized racial and ethnic groups. Poverty is one of the most significant challenges for our society in this millennium. Over 40% of the world lives in poverty. The U.S. has one of the highest rates of poverty in the developed world, despite its collective wealth, and the burden falls disproportionately on communities of color. A common narrative for the relatively high prevalence of poverty among marginalized minority communities is predicated on racist notions of racial inferiority and frequent denial of the structural forms of racism and classism that have contributed to public health crises in the United States and across the globe. Importantly, poverty is much more than just a low-income household. It reflects economic well-being, the ability to negotiate society relative to education of an individual, socioeconomic or health status, as well as social exclusion based on institutional policies, practices, and behaviors. Until structural racism and economic injustice can be resolved, the use of evidence-based prevention and early intervention initiatives to mitigate untoward effects of socioeconomic deprivation in communities of color such as the use of social media/culturally concordant health education, social support, such as social networks, primary intervention strategies, and more will be critical to address the persistent racial/ethnic disparities in chronic diseases.

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

BACKGROUND

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

OBJECTIVE

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

MAIN MEASURES

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

CONCLUSIONS

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

Rationale and design of a multicenter Chronic Kidney Disease (CKD) and at-risk for CKD electronic health records-based registry: CURE-CKD

BACKGROUND

Chronic kidney disease (CKD) is a global public health problem, exhibiting sharp increases in incidence, prevalence, and attributable morbidity and mortality. There is a critical need to better understand the demographics, clinical characteristics, and key risk factors for CKD; and to develop platforms for testing novel interventions to improve modifiable risk factors, particularly for the CKD patients with a rapid decline in kidney function.

METHODS

We describe a novel collaboration between two large healthcare systems (Providence St. Joseph Health and University of California, Los Angeles Health) supported by leadership from both institutions, which was created to develop harmonized cohorts of patients with CKD or those at increased risk for CKD (hypertension/HTN, diabetes/DM, pre-diabetes) from electronic health record data.

RESULTS

The combined repository of candidate records included more than 3.3 million patients with at least a single qualifying measure for CKD and/or at-risk for CKD. The CURE-CKD registry includes over 2.6 million patients with and/or at-risk for CKD identified by stricter guide-line based criteria using a combination of administrative encounter codes, physical examinations, laboratory values and medication use. Notably, data based on race/ethnicity and geography in part, will enable robust analyses to study traditionally disadvantaged or marginalized patients not typically included in clinical trials.

DISCUSSION

CURE-CKD project is a unique multidisciplinary collaboration between nephrologists, endocrinologists, primary care physicians with health services research skills, health economists, and those with expertise in statistics, bio-informatics and machine learning. The CURE-CKD registry uses curated observations from real-world settings across two large healthcare systems and has great potential to provide important contributions for healthcare and for improving clinical outcomes in patients with and at-risk for CKD.

Nephrologist Leadership in Advocacy and Public Policy

As a specialty and profession, nephrology has deep roots in the arenas of advocacy and public policy, with nephrologists playing a significant role in garnering legislative attention on the needs of patients with end-stage renal disease. The depth of experiences and unique perspectives of nephrologists and sharing our positions with legislators, regulators, and decision makers are central to achieving the Triple Aim for patients with kidney disease. Advocacy and public policy are conducted externally as well as internally to the House of Medicine and shape the future of kidney care and nephrology practice. This article explores the impact of nephrology leadership on government decision making and the important role of the nephrologist in advocacy and public policy at the Federal, state, and regional levels.

Global Kidney Health Atlas (GKHA): design and methods

There has been considerable effort within individual countries to improve the care of patients with kidney disease. There has been no concerted attempt to summarize these efforts, and therefore little is known about structuring health systems to facilitate acute kidney injury and chronic kidney disease (CKD) care and integration with national and international noncommunicable disease strategies. As part of the "Closing the Gaps Initiative," the International Society of Nephrology will conduct for the first time a survey of the current state of global kidney care covering both acute kidney injury and CKD and present the results in a Global Kidney Health Atlas. Data will be collected via an online questionnaire and targeted at national nephrology societies, policymakers, and consumer organizations. Individual country information will be provided by at least 3 stakeholders. The Global Kidney Health Atlas will provide concise, relevant, and synthesized information on the delivery of care across different health systems to facilitate understanding of performance variations over time and between countries. First, it will provide an overview of existing CKD care policy and context in the health care system. Second, it will provide an overview of how CKD care is organized in individual countries and a description of relevant CKD epidemiology between countries and regions, focusing on elements that are most germane to service delivery and policy development. Finally, synthesis, comparison, and analysis of individual country/regional data will be provided as a platform for recommendations to policymakers, practitioners, and researchers.

The effectiveness of multidisciplinary care models for patients with chronic kidney disease: a systematic review and meta-analysis

Aim

To assess the efficacy of the multidisciplinary care (MDC) model for patients with chronic kidney disease (CKD).

Background

The MDC model has been used in clinical practice for years, but the effectiveness of the MDC model for patients with CKD remains controversial.

Methods

Embase, PubMed, Medline, the Cochrane Library, and China National Knowledge Infrastructure databases were used to search for relevant articles. Only randomized controlled trials and cohort studies were pooled. Two independent authors assessed all articles and extracted the data. The efficacy was estimated from the odds ratios and corresponding 95% confidence intervals. A random effects model was used according to the heterogeneity.

Results

Twenty-one studies including 10,284 participants were analyzed. Compared with the non-MDC group, MDC was associated with a lower risk of all-cause mortality and lower hospitalization rates for patients with CKD. In addition, MDC also resulted in a slower eGFR decline and reduced temporary catheterization for patients receiving dialysis. However, according to the subgroup analysis, the lower rates of all-cause mortality in the MDC group were observed only in patients in stage 4–5 and when the staff of the MDC consisted of nephrologists, nurse specialists and professionals from other fields. The most prominent effect of reducing the hospitalization rates was also observed in patients with stage 4–5 but not in patients with stage 4–5 CKD.

Conclusions

MDC can lower the all-cause mortality of patients with CKD, reduce temporary catheterization for patients receiving dialysis, decrease the hospitalization rate, and slow the eGFR decline. Moreover, the reduction in all-cause mortality crucially depends on the professionals comprising the MDC staff and the stage of CKD in patients. In addition, the CKD stage influences the hospitalization rates.

Prevalence of chronic kidney disease defined by using CKD-EPI equation and albumin-to-creatinine ratio in the Korean adult population

BACKGROUND/AIMS

An updated chronic kidney disease (CKD) definition and classification were proposed by Kidney Disease: Improving Global Outcomes (KDIGO), with adoption of a new equation to estimate glomerular filtration rate (GFR) and albuminuria to evaluate kidney structural damage. This study was performed to estimate the prevalence of CKD in the Korean adult population as defined and classified by the KDIGO guidelines.

METHODS

Cross-sectional samples of the fifth Korean National Health and Nutrition Examination Survey for 2011 to 2012 were examined for adults aged ≥ 19 years. CKD prevalence was determined based on decreased GFR and albuminuria. The GFR was estimated using the CKD Epidemiology Collaboration creatinine equation, and albuminuria was evaluated using the albumin-to-creatinine ratio (ACR) in spot urine.

RESULTS

Of the 16,576 subjects participating in the survey, 10,636 (4,758 men, 5,878 women) were included in the present study. The prevalence of CKD was estimated as 7.9% (7.8% in 2011 and 8.0% in 2012, p = 0.770). The prevalence of low, moderately increased, high, and very high CKD risk prognosis was 92.0%, 6.3%, 1.1%, and 0.6%, respectively. The prevalence of albuminuria (ACR ≥ 30 mg/g) in individuals with GFR ≥ 60 mL/min/1.73 m² has reached 5.7%. The odds ratios of hypertension and diabetes to CKD were 3.4 and 3.1 in men, and 2.9 and 2.0 in women (all p < 0.001), respectively.

CONCLUSIONS

A large percentage of CKD patients had albuminuria prior to a decrease in GFR. Regular laboratory tests for albuminuria for the high-risk group, and especially for hypertensive or diabetic patients, might improve detection of CKD at an early stage.

Is preterm delivery an independent risk factor for long-term maternal kidney disease?. J Matern Fetal Neonatal Med 2016;30:1102-1107. [PMID: 27334094 DOI: 10.1080/14767058.2016.1205022]

OBJECTIVE

To investigate whether women who had a preterm delivery (PTD) are at an increased risk of subsequent long term maternal kidney disease.

STUDY DESIGN

A population-based study compared the incidence of long-term maternal kidney disease in a cohort of women with and without previous PTD. Deliveries occurred during a 25 years period, with a mean follow-up duration of 11.2 years.

RESULTS

Of 99 338 deliveries of women, 16 364 (16.4%) occurred in patients who had at least one PTD. A significant dose response was found between the number of previous PTDs and the gestational age at birth of the PTDs and future risk for renal-related hospitalizations. Patients with either spontaneous or indicated PTD had higher rates of renal-related hospitalizations (0.2% versus 0.1% OR= 2.6; 95%CI: 1.7-3.9, p  <0.001 and 0.5% versus 0.2% OR 3.41; 95%CI: 1.7-6.5, p  < 0.001, respectively). In a Cox proportional hazards model, PTD was independently associated with long-term maternal renal-related hospitalizations.

CONCLUSIONS

PTD is an independent risk factor for long-term maternal kidney disease.

The Economics of Late-Stage Chronic Kidney Disease

Health care reimbursement is undergoing a fundamental change from volume-driven to value-driven care. The Patient Protection and Affordable Care Act is marshaling this change and empowering hospitals through Accountable Care Organizations to accept risk. ESRD care/nephrology was awarded the only disease-specific Accountable Care Organization, ESRD Seamless Care Organizations. Dialysis providers in partnership with nephrologists will be exploring how ESRD Seamless Care Organizations will drive improvement in care. CKD care and economics will no longer be isolated from ESRD but possibly more closely linked to global patient outcomes. Preparation for these changes will require unique co-operation and collaboration between nephrologists, dialysis providers, payers, and hospitals/health care systems. Early pilot trials, demonstration projects, and special need programs have suggested value care can be delivered. Whether these results are scalable needs to be determined.

Epidemiology and Challenges to the Management of Advanced CKD

Advanced CKD is a period of CKD that differs greatly from earlier stages of CKD in terms of treatment goals. Treatment during this period presents particular challenges as further loss of kidney function heralds the need for renal replacement therapy. Successful management during this period increases the likelihood of improved transitions to ESRD. However, there are substantial barriers to optimal advanced CKD care. In this review, we will discuss advanced CKD definitions and epidemiology and outcomes.

Relationship Between Age and Pre-End Stage Renal Disease Care in Elderly Patients Treated with Maintenance Hemodialysis

Receipt of pre-end stage renal disease (ESRD) clinical care can improve outcomes for patients treated with maintenance hemodialysis (HD). This study addressed age-related variations in receipt of a composite of recommended care to include nephrologist and dietician care, and use of an arteriovenous fistula at first outpatient maintenance HD. Less than 2% of patients treated with maintenance HD received all three forms of pre-ESRD care, and 63.3% received none of the three elements of care. The mean number of pre-ESRD care elements received by the oldest group (80 years and older) did not differ from the youngest group (less than 55 years), but was less than the 55 to 66 and 67 to 79 years groups; adjusted ratios of 0.93 (0.92 to 0.94; p < 0.001) and 0.94 (0.92 to 0.95; p < 0.001), respectively. A major effort is needed to ensure comprehensive pre-ESRD care for all patients with advanced chronic kidney disease (CKD), especially for the youngest and oldest patient groups, who were less likely to receive recommended pre-ESRD care.

Socioeconomic disparities in chronic kidney disease

CKD is a national public health problem that afflicts persons of all segments of society. Although racial/ethnic disparities in advanced CKD including dialysis-dependent populations have been well established, the finding of differences in CKD incidence, prevalence, and progression across different socioeconomic groups and racial and ethnic strata has only recently started to receive significant attention. Socioeconomics may exert both interdependent and independent effects on CKD and its complications and may confound racial and ethnic disparities. Socioeconomic constellations influence not only access to quality care for CKD risk factors and CKD treatment but may mediate many of the cultural and environmental determinants of health that are becoming more widely recognized as affecting complex medical disorders. In this article, we have reviewed the available literature pertaining to the role of socioeconomic status and economic factors in both non-dialysis-dependent CKD and ESRD. Advancing our understanding of the role of socioeconomic factors in patients with or at risk for CKD can lead to improved strategies for disease prevention and management.

Relationship Between Age and Timely Placement of Vascular Access In Incident Patients on Hemodialysis

BACKGROUND AND PURPOSE

Placement of an arteriovenous fistula (AV) prior to initiating hemodialysis can affect clinical outcomes for patients who subsequently initiate chronic hemodialysis treatments. Age-related variation in receipt of a functioning A TF prior to initiating hemodialysis is not well known. The purpose of this study was to examine age-related rates in use of AVF at the first outpatient hemodialysis treatment among U.S. incident patients on hemodialysis.

FINDINGS

Among 526,145 patients identified, the use of AVF outpatient hemodialysis treatment was lower in the youngest (younger than 55 years) and oldest (80 years and older) vs. both 55 to 66-year and 67 to 79-year age groups. These findings persisted after adjusting for demographics, lifestyle behavior, employment and insurance status, physical/functional conditions, and co-morbid conditions.

CONCLUSIONS

The presence of a functioning AVF at initial hemodialysis treatment varies by age. Modifying healthcare policy and/or expanding the role of nephrology nurses should be considered to address this issue.

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

BACKGROUND

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

STUDY DESIGN

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

SETTING & PARTICIPANTS

9 PCP and 5 nephrology practices in Philadelphia and Chicago.

QUALITY IMPROVEMENT PLAN

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

OUTCOMES

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

MEASUREMENTS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

MRI-detectable nanoparticles: the potential role in the diagnosis of and therapy for chronic kidney disease

Chronic kidney disease (CKD) is a common, deadly, and expensive threat to public health. Patients susceptible to the development of CKD are difficult to identify because there are few noninvasive clinical techniques and markers to assess early kidney dysfunction. Noninvasive imaging techniques are being developed to quantitatively measure kidney morphology and function in preclinical research and in clinical trials. Magnetic resonance imaging (MRI) techniques in particular have the potential to provide structural and functional information in the kidney. Novel molecular imaging techniques, using targeted magnetic nanoparticles that exploit the characteristics of the endogenous protein, ferritin, have been developed in conjunction with MRI to count every perfused glomerulus in the kidney and measure their individual volumes. This technique could open the door to the possibility of prospectively assessing and eventually reducing a patient's risk for progression to CKD. This review highlights the potential clinical benefits of early detection in patients predisposed to CKD and discusses technologic and regulatory hurdles to the translation of these molecular MRI techniques to provide early diagnosis of CKD.

The British Columbia Nephrologists' Access Study (BCNAS) - a prospective, health services interventional study to develop waiting time benchmarks and reduce wait times for out-patient nephrology consultations

Background

Early referral and management of high-risk chronic kidney disease may prevent or delay the need for dialysis. Automatic eGFR reporting has increased demand for out-patient nephrology consultations and in some cases, prolonged queues. In Canada, a national task force suggested the development of waiting time targets, which has not been done for nephrology.

Methods

We sought to describe waiting time for outpatient nephrology consultations in British Columbia (BC). Data collection occurred in 2 phases: 1) Baseline Description (Jan 18-28, 2010) and 2) Post Waiting Time Benchmark-Introduction (Jan 16-27, 2012). Waiting time was defined as the interval from receipt of referral letters to assessment. Using a modified Delphi process, Nephrologists and Family Physicians (FP) developed waiting time targets for commonly referred conditions through meetings and surveys. Rules were developed to weigh-in nephrologists’, FPs’, and patients’ perspectives in order to generate waiting time benchmarks. Targets consider comorbidities, eGFR, BP and albuminuria. Referred conditions were assigned a priority score between 1-4. BC nephrologists were encouraged to centrally triage referrals to see the first available nephrologist. Waiting time benchmarks were simultaneously introduced to guide patient scheduling. A post-intervention waiting time evaluation was then repeated.

Results

In 2010 and 2012, 43/52 (83%) and 46/57 (81%) of BC nephrologists participated. Waiting time decreased from 98(IQR44,157) to 64(IQR21,120) days from 2010 to 2012 (p = <.001), despite no change in referral eGFR, demographics, nor number of office hrs/wk. Waiting time improved most for high priority patients.

Conclusions

An integrated, Provincial initiative to measure wait times, develop waiting benchmarks, and engage physicians in active waiting time management associated with improved access to nephrologists in BC. Improvements in waiting time was most marked for the highest priority patients, which suggests that benchmarks had an influence on triaging behavior. Further research is needed to determine whether this effect is sustainable.

Use of administrative databases for health-care planning in CKD

Good-quality information is required to plan healthcare services for patients with chronic diseases. Such information includes measures of disease burden, current care patterns and gaps in care based on quality-of-care indicators and clinical outcomes. Administrative data have long been used as a source of information for policy decisions related to the management of chronic diseases including cardiovascular disease, diabetes and hypertension. More recently, chronic kidney disease (CKD) has been acknowledged as a significant public health issue. Administrative data, particularly when supplemented by the use of routine laboratory data, have the potential to inform the development of optimal CKD care strategies, generate hypotheses about how to slow disease progression and identify risk factors for adverse outcomes. Available data may allow case identification and assessment of rates and patterns of disease progression, evaluation of risk and complications, including current gaps in care, and an estimation of associated costs. In this article, we use the example of the Alberta Kidney Disease Network to describe how researchers and policy makers can collaborate, using administrative data sources to guide health policy for the care of CKD patients.

The association of moderate renal dysfunction with impaired preference-based health-related quality of life: third Korean national health and nutritional examination survey

Background

Only a few large-scale studies have investigated the association between health-related quality of life (HRQOL) and renal function. Moreover, the HRQOL of patients with moderate renal dysfunction is frequently underestimated by healthcare providers. This study assessed the impact of renal function on preference-based HRQOL in Korean adult population.

Methods

We analyzed data for 5,555 adults from the 3^rd Korean National Health and Nutritional Examination Survey 2005. The EuroQol-5D (EQ-5D) utility score was used to evaluate HRQOL. The study subjects were stratified into three groups based on their estimated glomerular filtration rates (eGFRs): ≥ 90.0, 60.0-89.9 and 30.0-59.9 mL/min/1.73 m². Individuals with advanced renal dysfunction were excluded from the analysis.

Results

The proportions of participants who reported problems in each of the five EQ-5D dimensions increased significantly with decreasing eGFR. However, a significant decrease in the EQ-5D utility score was observed among participants with an eGFR of 30.0-59.9 mL/min/1.73 m². Participants with an eGFR of 30.0-59.9 mL/min/1.73 m² had an almost 1.5-fold higher risk of impaired health utility (the lowest quartile of EQ-5D utility score) compared with those participants with eGFRs ≥ 90.0 mL/min/1.73 m², after adjustment for age, gender, health-related behaviors, socioeconomic and psychological variables, and other comorbidities. Among the five dimensions of the EQ-5D, an eGFR of 30.0-59.9 mL/min/1.73 m² was an independent determinant of self-reported problems in the mobility and pain/discomfort dimensions.

Conclusions

Although age affects the association between renal dysfunction and the EQ-5D, moderate renal dysfunction seems to be an important determinant of impaired health utility in a general population and may affect the mobility and pain/discomfort dimensions of health utility.

Aldosterone blockade and the mineralocorticoid receptor in the management of chronic kidney disease: current concepts and emerging treatment paradigms

The past two decades have witnessed a striking paradigm shift with respect to our understanding of the widespread effects of aldosterone. There is substantive evidence that mineralocorticoid receptor (MR) activation promotes myriad 'off target' effects on the heart, the vasculature, and importantly the kidney. In the present review, we summarize the expanding role of MR activation in promoting both vascular and renal injury. We review the recent clinical studies that investigated the efficacy of MR antagonism (MRA) in reducing proteinuria and attenuating progressive renal disease. We also review in-depth both the utility and safety of MRA in the end-stage renal disease (ESRD) patient undergoing dialysis. Because the feasibility of add-on MRA is critically dependent on our ability to minimize or avoid hyperkalemia, and because controversy centers on the incidence of hyperkalemia, we critically review the risk of hyperkalemia with add-on MRA. Our present analysis suggests that hyperkalemia supervening in MRA-treated patients is overstated. Furthermore, recent studies demonstrating the efficacy of new non-absorbed, orally administered, potassium [K+]-binding polymers suggest that a multi-pronged approach encompassing adequate surveillance, moderate or low-dose MRA, and K-binding polymers may adequately control serum K in both chronic kidney disease and ESRD patients.

Chronic kidney disease

Chronic kidney disease is a general term for heterogeneous disorders affecting kidney structure and function. The 2002 guidelines for definition and classification of this disease represented an important shift towards its recognition as a worldwide public health problem that should be managed in its early stages by general internists. Disease and management are classified according to stages of disease severity, which are assessed from glomerular filtration rate (GFR) and albuminuria, and clinical diagnosis (cause and pathology). Chronic kidney disease can be detected with routine laboratory tests, and some treatments can prevent development and slow disease progression, reduce complications of decreased GFR and risk of cardiovascular disease, and improve survival and quality of life. In this Seminar we discuss disease burden, recommendations for assessment and management, and future challenges. We emphasise clinical practice guidelines, clinical trials, and areas of uncertainty.

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

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

Baseline characteristics of patients with chronic kidney disease stage 3 and stage 4 in Spain: the MERENA observational cohort study

Background

To obtain information on cardiovascular morbidity, hypertension control, anemia and mineral metabolism based on the analysis of the baseline characteristics of a large cohort of Spanish patients enrolled in an ongoing prospective, observational, multicenter study of patients with stages 3 and 4 chronic kidney diseases (CKD).

Methods

Multicenter study from Spanish government hospital-based Nephrology outpatient clinics involving 1129 patients with CKD stages 3 (n = 434) and 4 (n = 695) defined by GFR calculated by the MDRD formula. Additional analysis was performed with GFR calculated using the CKD-EPI and Cockcroft-Gault formula.

Results

In the cohort as a whole, median age 70.9 years, morbidity from all cardiovascular disease (CVD) was very high (39.1%). In CKD stage 4, CVD prevalence was higher than in stage 3 (42.2 vs 35.6% p < 0.024). Subdividing stage 3 in 3a and 3b and after adjusting for age, CVD increased with declining GFR with the hierarchy (stage 3a < stage 3b < stage 4) when calculated by CKD-EPI (31.8, 35.4, 42.1%, p 0.039) and Cockcroft-Gault formula (30.9, 35.6, 43.4%, p 0.010) and MDRD formula (32.5, 36.2, 42.2%,) but with the latter, it did not reach statistical significance (p 0.882). Hypertension was almost universal among those with stages 3 and 4 CKD (91.2% and 94.1%, respectively) despite the use of more than 3 anti-hypertensive agents including widespread use of RAS blockers. Proteinuria (> 300 mg/day) was present in more than 60% of patients and there was no significant differences between stages 3 and 4 CKD (1.2 ± 1.8 and 1.3 ± 1.8 g/day, respectively). A majority of the patients had hemoglobin levels greater than 11 g/dL (91.1 and 85.5% in stages 3 and 4 CKD respectively p < 0.001) while the use of erythropoiesis-stimulating agents (ESA) was limited to 16 and 34.1% in stages 3 and 4 CKD respectively. Intact parathyroid hormone (i-PTH) was elevated in stage 3 and stage 4 CKD patients (121 ± 99 and 166 ± 125 pg/mL p 0.001) despite good control of calcium-phosphorus levels.

Conclusion

This study provides an overview of key clinical parameters in patients with CKD Stages 3 and 4 where delivery or care was largely by nephrologists working in a network of hospital-based clinics of the Spanish National Healthcare System.

Performance measurement in chronic kidney disease

Do Americans receive high-value health care? Value only improves by advancing key indicators in one of two directions: increasing quality, decreasing cost, or both. In the face of unyielding mortality rates and the relentless expense of end-stage renal disease, government agencies and professional organizations are now focusing on new quality measures for patients with advancing chronic kidney disease. These performance measures are in early stages of refinement but reflect efforts of payers to slow the incidence of progressive renal disease across the population. To improve quality of care, one must study the performance measures themselves and determine how to capture the necessary data efficiently, identify the appropriate patients for measurement, and assign accountability to providers. Here, we discuss the challenges of doing this well.