Cardiovascular risk management in chronic kidney disease in general practice (the AusHEART study)

Effectiveness of Electronic Quality Improvement Activities to Reduce Cardiovascular Disease Risk in People With Chronic Kidney Disease in General Practice: Cluster Randomized Trial With Active Control

BACKGROUND

Future Health Today (FHT) is a program integrated with electronic medical record (EMR) systems in general practice and comprises (1) a practice dashboard to identify people at risk of, or with, chronic disease who may benefit from intervention; (2) active clinical decision support (CDS) at the point of care; and (3) quality improvement activities. One module within FHT aims to facilitate cardiovascular disease (CVD) risk reduction in people with chronic kidney disease (CKD) through the recommendation of angiotensin-converting enzyme inhibitor inhibitors (ACEI), angiotensin receptor blockers (ARB), or statins according to Australian guidelines (defined as appropriate pharmacological therapy).

OBJECTIVE

This study aimed to determine if the FHT program increases the proportion of general practice patients with CKD receiving appropriate pharmacological therapy (statins alone, ACEI or ARB alone, or both) to reduce CVD risk at 12 months postrandomization compared with active control (primary outcome).

METHODS

General practices recruited through practice-based research networks in Victoria and Tasmania were randomly allocated 1:1 to the FHT CKD module or active control. The intervention was delivered to practices between October 4, 2021, and September 30, 2022. Data extracted from EMRs for eligible patients identified at baseline were used to evaluate the trial outcomes at the completion of the intervention period. The primary analysis used an intention-to-treat approach. The intervention effect for the primary outcome was estimated with a marginal logistic model using generalized estimating equations with robust SE.

RESULTS

Overall, of the 734 eligible patients from 19 intervention practices and 715 from 21 control practices, 82 (11.2%) and 70 (9.8%), respectively, had received appropriate pharmacological therapy (statins alone, ACEI or ARB alone, or both) at 12 months postintervention to reduce CVD risk, with an estimated between-trial group difference (Diff) of 2.0% (95% CI -1.6% to 5.7%) and odds ratio of 1.24 (95% CI 0.85 to 1.81; P=.26). Of the 470 intervention patients and 425 control patients that received a recommendation for statins, 61 (13%) and 38 (9%) were prescribed statins at follow-up (Diff 4.3%, 95% CI 0 to 8.6%; odds ratio 1.55, 95% CI 1.02 to 2.35; P=.04). There was no statistical evidence to support between-group differences in other secondary outcomes and general practice health care use.

CONCLUSIONS

FHT harnesses the data stored within EMRs to translate guidelines into practice through quality improvement activities and active clinical decision support. In this instance, it did not result in a difference in prescribing or clinical outcomes except for small changes in statin prescribing. This may relate to COVID-19-related disruptions, technical implementation challenges, and recruiting higher performing practices to the trial. A separate process evaluation will further explore factors impacting implementation and engagement with FHT.

TRIAL REGISTRATION

ACTRN12620000993998; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380119.

Prevalence of chronic kidney disease in Western Australia, 2010-2020

OBJECTIVE

To assess the prevalence and trends of chronic kidney disease (CKD) in Western Australia (WA) from 2010 to 2020 using linked pathology data.

DESIGN

A retrospective observational cohort study using linked de-identified data from WA pathology providers, hospital morbidity records and mortality records.

SETTING

A Western Australian population-based study.

PARTICIPANTS

All individuals aged 18 years and older with at least one serum creatinine test.

PRIMARY OUTCOME MEASURE

CKD status as determined by estimated glomerular filtration rate and urine albumin-creatinine ratio.

RESULTS

Analysing data from 2 501 188 individuals, there was a significant increase in age-sex standardised CKD prevalence from 4.7% in 2010 to 6.0% in 2020, with annual average percentage change of 3.0% (95% CI: 2.3% to 3.7%). Prevalence of CKD stages 3 and above was 4.8% in 2020. Higher CKD prevalence was observed in regional and remote areas compared with major cities, and among individuals in the most socioeconomically disadvantaged quintiles. Sensitivity analysis indicated minor impacts from data exclusions and methodological choices.

CONCLUSIONS

CKD prevalence in WA has been steadily increasing, reflecting broader Australian trends. The study highlights significant disparities in CKD prevalence based on age, socioeconomic status and geographic remoteness.

Decarbonisation of Kidney Care in the United Arab Emirates: A Roadmap to an Environmentally Sustainable Care

Chronic kidney disease (CKD) remains a major public health burden and a leading cause of mortality worldwide and in the United Arab Emirates (UAE). Alongside its clinical and humanistic burden, CKD care is associated with a significant carbon footprint. In this narrative review, we present an overview of the carbon footprint of current CKD treatments and the results of an analysis estimating the carbon footprint of CKD treatments in the UAE. Using the life cycle assessment (LCA) method and local data from the published national reports and inventory sources, we estimated that haemodialysis leads to greenhouse gas (GHG) emissions of ~12.8 tons of CO2 equivalents (CO2eq) per person in the UAE annually. Thus, the decarbonisation of CKD care is crucial in establishing an environmentally sustainable healthcare system. We propose a framework to decarbonise CKD care in the UAE that tackles the carbon footprint of CKD care in the UAE by focusing on three main pillars: Delaying early CKD and slowing its progression; reducing anthropogenic emissions from CKD and dialysis care by promoting best practices and eco-friendly technologies; and enhancing access to kidney transplantation. Such approaches are relevant not only for the UAE but also for global healthcare systems aiming towards net-zero emissions.

General practitioners' assessment and management of chronic kidney disease in older patients- a mixed methods study

BACKGROUND

Chronic kidney disease (CKD) is commonly managed in general practice, with established guidelines for diagnosis and management. CKD is more prevalent in the older population, and is associated with lifestyle diseases as well as social deprivation. Older patients also commonly experience multimorbidity. Current CKD guidelines do not take age into account, with the same diagnostic and management recommendations for patients regardless of their age. We sought to investigate general practitioners' (GPs') approach to older patients with CKD, and whether their assessment and management differed from guideline recommendations. We explored the reasons for variation from guideline recommendations.

METHODS

This was a mixed methods study of Australian GPs. An online anonymous survey about the use of CKD guidelines, and assessment and management of CKD was sent to 9500 GPs. Four hundred and sixty-nine (5%) of GPs responded, and the survey was completed by 399 GPs. Subsequently, 27 GPs were interviewed in detail about their diagnostic and management approach to older patients with declining kidney function.

RESULTS

In the survey, 48% of GPs who responded found the CKD guidelines useful for diagnosis and management. Four themes arose from our interviews: age-related decline in kidney function; whole person care; patient-centred care; and process of care that highlighted the importance of continuity of care. GPs recognised that older patients have an inherently high risk of lower kidney function. The GPs reported management of that higher risk focused on managing the whole person (not just a single disease focus) and being patient-centred. Patient-centred care expressed the importance of quality of life, shared decision making and being symptom focused. There was also a recognition that there is a difference between a sudden decline in kidney function and a stable but low kidney function and GPs would manage these situations differently.

CONCLUSIONS

GPs apply guidelines in the management of CKD in older patients using a patient-centred and whole person approach to care. Older patients have a high prevalence of multimorbidity, which GPs carefully considered when applying existing CKD-specific guidelines. Future iterations of CKD Guidelines need to give due consideration to multimorbidity in older patients that can adversely impact on kidney function in addition to the expected age-related functional decline.

Use of kidney failure risk equation as a tool to evaluate referrals from primary care to specialist nephrology care

BACKGROUND

With rising costs and burden of chronic kidney disease (CKD), timely referral of patients to a kidney specialist is crucial. Currently, Kidney Health Australia (KHA) uses a 'heat map' based on severity and not future risk of kidney failure, whereas the kidney failure risk equation (KFRE) score predicts future risk of progression.

AIMS

Evaluate whether a KFRE score assists with timing of CKD referrals.

METHODS

Retrospective cohort of 2137 adult patients, referred to tertiary hospital outpatient nephrologist between 2012 and 2020, were analysed. Referrals were analysed for concordance with the KHA referral guidelines and, with the KFRE score, a recommended practice.

RESULTS

Of 2137 patients, 626 (29%) did not have urine albumin-to-creatinine ratio (UACR) measurement at referral. For those who had a UACR, the number who met KFRE preferred referral criteria was 36% less than KHA criteria. If the recommended KFRE score was used, then fewer older patients (≥40 years) needed referral. Positively, many diabetes patients were referred, even if their risk of kidney failure was low, and 29% had a KFRE over 3%. For patients evaluated meeting KFRE criteria, a larger proportion (76%) remained in follow-up, with only 8% being discharged.

CONCLUSIONS

KFRE could reduce referrals and be a useful tool to assist timely referrals. Using KFRE for triage may allow those patients with very low risk of future kidney failure not be referred, remaining longer in primary care, saving health resources and reducing patients' stress and wait times. Using KFRE encourages albuminuria measurement.

Participant and GP perspectives and experiences of screening for undiagnosed type 2 diabetes in community pharmacy during the Pharmacy Diabetes Screening Trial

BACKGROUND

The Pharmacy Diabetes Screening Trial (PDST) evaluated three approaches to screening for undiagnosed type 2 diabetes mellitus (T2DM) in community pharmacy: (1) paper-based risk assessment (AUSDRISK) alone; and AUSDRISK followed by a point of care test if AUSDRISK ≥ 12; with either (2) HbA1c; or (3) small capillary blood glucose Test (scBGT). This paper reports the perspectives and experiences of the pharmacy screening service of two key stakeholder groups: screening participants and general practitioners (GPs).

METHODS

All referred participants (n = 2242) received an online survey to determine the outcome of the referral, as well as their level of satisfaction with the service. In addition, a random sample of 2,989 (20%) of non-referred participants were surveyed to determine their overall experience and level of satisfaction with the service. GPs to whom participants were referred were contacted to establish if, since the date of the screening service, their patient had (1) been to see them; (2) had further tests performed (FBG, RBG, OGTT, HbA1c); or (3) been diagnosed with diabetes or prediabetes. Descriptive statistics were reported for quantitative data. Factors associated with visiting the GP following screening were assessed using multivariable logistic regression. Qualitative data were analysed using content analysis.

RESULTS

Response rates 16% (n = 369) and 17% (n = 520) were achieved for the three-month referred and non-referred participant surveys, respectively. Over 90% of respondents were very positive about the screening service (n = 784/853) and would recommend it to a family member or friend (n = 784/853). Participants also reported making significant improvements in diet and exercise, because of the screening. Among referred respondents, those who received a POC test were twice as likely to visit their GP compared to those who received a risk assessment only (OR 2.11 95% CI 1.46-3.06). GPs (15.8% response rate, n = 57/361) indicated that the referral worked well and that recommendations for follow-up care by the pharmacist were appropriate.

CONCLUSION

Opportunistic screening of individuals during routine encounters with the community pharmacy in a previously undiagnosed population has been shown to foster positive engagement with consumers and GPs, which may assist in reducing the burden of T2DM on the individual and the community.

Chronic Kidney Disease Management in the Middle East and Africa: Concerns, Challenges, and Novel Approaches

The burden of chronic kidney disease (CKD) and other comorbidities, such as hypertension and diabetes, which increase the risk of developing CKD, is on the rise in the Middle East and Africa. The Middle East and Africa CKD (MEA-CKD) steering committee, comprising eminent healthcare specialists from the Middle East and Africa, was formed to identify and propose steps to address the gaps in the management of CKD in these regions. The current article lists the MEA-CKD steering committee meeting outcomes and evaluates the available evidence supporting the role of novel therapeutic options for patients with CKD. The need of the hour is to address the gaps in awareness and screening, early diagnosis, along with referral and management of patients at risk. Measures to bring about appropriate changes in healthcare policies to ensure access to all benefit-proven protective therapies, including novel ones, at community levels are also vital for reducing the overall burden of CKD on the healthcare system as well as governing bodies, especially in developing countries of the Middle East and Africa.

Using electronic medical record data to assess chronic kidney disease, type 2 diabetes and cardiovascular disease testing, recognition and management as documented in Australian general practice: a cross-sectional analysis

Objectives

To evaluate the capacity of general practice (GP) electronic medical record (EMR) data to assess risk factor detection, disease diagnostic testing, diagnosis, monitoring and pharmacotherapy for the interrelated chronic vascular diseases—chronic kidney disease (CKD), type 2 diabetes (T2D) and cardiovascular disease.

Design

Cross-sectional analysis of data extracted on a single date for each practice between 12 April 2017 and 18 April 2017 incorporating data from any time on or before data extraction, using baseline data from the Chronic Disease early detection and Improved Management in PrimAry Care ProjecT. Deidentified data were extracted from GP EMRs using the Pen Computer Systems Clinical Audit Tool and descriptive statistics used to describe the study population.

Setting

Eight GPs in Victoria, Australia.

Participants

Patients were ≥18 years and attended GP ≥3 times within 24 months. 37 946 patients were included.

Results

Risk factor and disease testing/monitoring/treatment were assessed as per Australian guidelines (or US guidelines if none available), with guidelines simplified due to limitations in data availability where required. Risk factor assessment in those requiring it: 30% of patients had body mass index and 46% blood pressure within guideline recommended timeframes. Diagnostic testing in at-risk population: 17% had diagnostic testing as per recommendations for CKD and 37% for T2D. Possible undiagnosed disease: Pathology tests indicating possible disease with no diagnosis already coded were present in 6.7% for CKD, 1.6% for T2D and 0.33% familial hypercholesterolaemia. Overall prevalence: Coded diagnoses were recorded in 3.8% for CKD, 6.6% for T2D, 4.2% for ischaemic heart disease, 1% for heart failure, 1.7% for ischaemic stroke, 0.46% for peripheral vascular disease, 0.06% for familial hypercholesterolaemia and 2% for atrial fibrillation. Pharmaceutical prescriptions: the proportion of patients prescribed guideline-recommended medications ranged from 44% (beta blockers for patients with ischaemic heart disease) to 78% (antiplatelets or anticoagulants for patients with ischaemic stroke).

Conclusions

Using GP EMR data, this study identified recorded diagnoses of chronic vascular diseases generally similar to, or higher than, reported national prevalence. It suggested low levels of extractable documented risk factor assessments, diagnostic testing in those at risk and prescription of guideline-recommended pharmacotherapy for some conditions. These baseline data highlight the utility of GP EMR data for potential use in epidemiological studies and by individual practices to guide targeted quality improvement. It also highlighted some of the challenges of using GP EMR data.

Sex differences in mortality among binational cohort of people with chronic kidney disease: population based data linkage study

OBJECTIVE

To evaluate sex differences in mortality among people with kidney failure compared with the general population.

DESIGN

Population based cohort study using data linkage.

SETTING

The Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), which includes all patients receiving kidney replacement therapy in Australia (1980-2019) and New Zealand (1988-2019). Data were linked to national death registers to determine deaths and their causes, with additional details obtained from ANZDATA.

PARTICIPANTS

Of 82 844 people with kidney failure, 33 329 were female (40%) and 49 555 were male (60%); 49 376 deaths (20 099 in female patients; 29 277 in male patients) were recorded over a total of 536 602 person years of follow-up.

MAIN OUTCOME MEASURES

Relative measures of survival, including standardised mortality ratios, relative survival, and years of life lost, using general population data to account for background mortality (adjusting for country, age, sex, and year). Estimates were stratified by dialysis modality (haemodialysis or peritoneal dialysis) and for the subpopulation of kidney transplant recipients.

RESULTS

Few differences in outcomes were found between male and female patients with kidney failure. However, compared with the general population, female patients with kidney failure had greater excess all cause deaths than male patients (female patients: standardised mortality ratio 11.3, 95% confidence interval 11.2 to 11.5, expected deaths 1781, observed deaths 20 099; male patients: 6.9, 6.8 to 6.9, expected deaths 4272, observed deaths 29 277). The greatest difference was observed among younger patients and those who died from cardiovascular disease. Relative survival was also consistently lower in female patients, with adjusted excess mortality 11% higher (95% confidence interval 8% to 13%). Average years of life lost was 3.6 years (95% confidence interval 3.6 to 3.7) greater in female patients with kidney failure compared with male patients across all ages. No major differences were found in mortality by sex for haemodialysis or peritoneal dialysis. Kidney transplantation reduced but did not entirely remove the sex difference in excess mortality, with similar relative survival (P=0.83) and years of life lost difference reduced to 2.3 years (95% confidence interval 2.2 to 2.3) between female and male patients.

CONCLUSIONS

Compared with the general population, female patients had greater excess deaths, worse relative survival, and more years of life lost than male patients, however kidney transplantation reduced these differences. Future research should investigate whether systematic differences exist in access to care and possible strategies to mitigate excess mortality among female patients.

Balancing the Risk-Benefit Ratio of Immune Checkpoint Inhibitor and Anti-VEGF Combination Therapy in Renal Cell Carcinoma: A Systematic Review and Meta-Analysis

Background

Although immune checkpoint inhibitors (ICIs) combined with vascular endothelial growth factor receptor (VEGFR)-targeted therapy and sunitinib monotherapy have been widely applied to metastatic renal cell carcinoma (mRCC), effectiveness and safety data are still lacking. To optimize clinical decision-making, we conducted a systematic review and meta-analysis of published randomized clinical trials to characterize the efficacy and the risk of adverse events (AEs) in patients treated with ICIs plus anti-VEGF therapy.

Materials and Methods

We used PubMed, EMBASE, and the Cochrane Library to retrieve randomized controlled trials (RCTs) published before March 27, 2021. The efficacy outcomes were progression-free survival (PFS), overall survival (OS), and objective response rate (ORR). The pooled risk ratio (RR) and 95% confidence intervals (CI) of AEs were calculated in the safety analysis.

Results

Six RCTs involving 4,227 patients were identified after a systematic search. For OS, ICI and anti-VEGF combination therapy decreased mortality approximately 30% in the intention-to-treat population (ITT) (hazard ratio (HR) = 0.70, 95% CI: 0.57–0.87), but there was no statistical difference in patients evaluated as “favorable” by the International Metastatic Renal-Cell Carcinoma Database Consortium (IMDC) criteria compared with monotherapy (HR = 0.90, 95% CI: 0.55–1.46, p = 0.66). In terms of PFS, the progression risk for all participants declined 35% (HR = 0.65, 95% CI: 0.50–0.83) and patients evaluated as “poor” by IMDC benefited further (HR = 0.46, 95% CI: 0.36–0.58). No evident divergence was found in age and sex subgroups. The RRs of all-grade hypertension, arthralgia, rash, proteinuria, high-grade (grades 3–5) arthralgia, and proteinuria developed after combination therapy were increased compared with sunitinib. The risk of high-grade hypertension and rash showed no statistical difference. However, the risk of hand-foot skin reaction (HFSR), stomatitis, and dysgeusia decreased in combination therapy groups.

Conclusions

Compared with sunitinib, OS, PFS, and ORR were significantly improved in patients receiving ICI and anti-VEGF combination therapy at the expense of increased specific AEs. More attention should be paid to individualized application of these combination therapies to achieve the best benefit-risk ratio in the clinic.

Systematic Review Registration

[https://inplasy.com/] INPLASY: 202130104.

Towards optimising chronic kidney disease detection and management in primary care: Underlying theory and protocol for technology development using an Integrated Knowledge Translation approach

Worldwide, Chronic Kidney Disease (CKD), directly or indirectly, causes more than 2.4 million deaths annually with symptoms generally presenting late in the disease course. Clinical guidelines support the early identification and treatment of CKD to delay progression and improve clinical outcomes. This paper reports the protocol for the codesign, implementation and evaluation of a technological platform called Future Health Today (FHT), a software program that aims to optimise early detection and management of CKD in general practice. FHT aims to optimise clinical decision making and reduce practice variation by translating evidence into practice in real time and as a part of quality improvement activities. This protocol describes the co-design and plans for implementation and evaluation of FHT in two general practices invited to test the prototype over 12 months. Service design thinking has informed the design phase and mixed methods will evaluate outcomes following implementation of FHT. Through systematic application of co-design with service users, clinicians and digital technologists, FHT attempts to avoid the pitfalls of past studies that have failed to accommodate the complex requirements and dynamics that can arise between researchers and service users and improve chronic disease management through use of health information technology.

The Preventable Productivity Burden of Kidney Disease in Australia

BACKGROUND

Kidney disease is associated with impaired work productivity. However, the collective effect of missed work days, reduced output at work, and early withdrawal from the workforce is rarely considered in health-economic evaluations.

METHODS

To determine the effect on work productivity of preventing incident cases of kidney disease, using the novel measure "productivity-adjusted life year" (PALY), we constructed a dynamic life table model for the Australian working-age population (aged 15-69 years) over 10 years (2020-2029), stratified by kidney-disease status. Input data, including productivity estimates, were sourced from the literature. We ascribed a financial value to the PALY metric in terms of gross domestic product (GDP) per equivalent full-time worker and assessed the total number of years lived, total PALYs, and broader economic costs (GDP per PALY). We repeated the model simulation, assuming a reduced kidney-disease incidence; the differences reflected the effects of preventing new kidney-disease cases. Outcomes were discounted by 5% annually.

RESULTS

Our projections indicate that, from 2020 to 2029, the estimated number of new kidney-disease cases will exceed 161,000. Preventing 10% of new cases of kidney disease during this period would result in >300 premature deaths averted and approximately 550 years of life and 7600 PALYs saved-equivalent to a savings of US$1.1 billion in GDP or US$67,000 per new case avoided.

CONCLUSIONS

Pursuing a relatively modest target for preventing kidney disease in Australia may prolong years of life lived and increase productive life years, resulting in substantial economic benefit. Our findings highlight the need for investment in preventive measures to reduce future cases of kidney disease.

The case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Chronic kidney disease (CKD) causes substantial global morbidity and increases cardiovascular and all-cause mortality. Unlike other chronic diseases with established strategies for screening, there has been no consensus on whether health systems and governments should prioritize early identification and intervention for CKD. Guidelines on evaluating and managing early CKD are available but have not been universally adopted in the absence of incentives or quality measures for prioritizing CKD care. The burden of CKD falls disproportionately upon persons with lower socioeconomic status, who have a higher prevalence of CKD, limited access to treatment, and poorer outcomes. Therefore, identifying and treating CKD at the earliest stages is an equity imperative. In 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a controversies conference entitled "Early Identification and Intervention in CKD." Participants identified strategies for screening, risk stratification, and treatment for early CKD and the key health system and economic factors for implementing these processes. A consensus emerged that CKD screening coupled with risk stratification and treatment should be implemented immediately for high-risk persons and that this should ideally occur in primary or community care settings with tailoring to the local context.

Dedicated kidney disease-focused outcome trials with sodium-glucose cotransporter-2 inhibitors: Lessons from CREDENCE and expectations from DAPA-HF, DAPA-CKD, and EMPA-KIDNEY

In the past decade, many cardiovascular outcome trials (CVOT) on the efficacy and safety of glucose-lowering agents have been completed. Amongst newer agents available for treatment of type 2 diabetes mellitus (T2DM), sodium-glucose cotransporter-2 (SGLT2) inhibitors have garnered much attention in contemporary clinical practice due to observed benefits on cardiovascular and kidney outcomes among patients with T2DM, as reported in large randomized controlled trials (RCT). These findings are reflected in the updated clinical guidelines of several major professional societies. Herein, we briefly review the mechanism of action of SGLT2 inhibitors and their pleiotropic effects, summarize key findings and limitations of initial CVOTs, then discuss three major kidney disease-focused outcome trials, including the Canagliflozin and Renal Events in Diabetes and Established Nephropathy Clinical Evaluation (CREDENCE) trial as well as two ongoing RCTs: Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure-chronic kidney disease and EMPA-KIDNEY.

Medication Prescribing Quality in Australian Primary Care Patients with Chronic Kidney Disease

Background: Australian patients with chronic kidney disease (CKD) are routinely managed in general practices with multiple medications. However, no nationally representative study has evaluated the quality of prescribing in these patients. The objective of this study was to examine the quality of prescribing in patients with CKD using nationally representative primary care data obtained from the NPS MedicineWise’s dataset, MedicineInsight. Methods: A cross-sectional analysis of general practice data for patients aged 18 years or older with CKD was performed from 1 February 2016 to 1 June 2016. The study examined the proportion of patients with CKD who met a set of 16 published indicators in two categories: (1) potentially appropriate prescribing of antihypertensives, renin-angiotensin system (RAS) inhibitors, phosphate binders, and statins; and (2) potentially inappropriate prescribing of nephrotoxic medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), at least two RAS inhibitors, triple therapy (an NSAID, a RAS inhibitor and a diuretic), high-dose digoxin, and metformin. The proportion of patients meeting each quality indicator was stratified using clinical and demographic characteristics. Results: A total of 44,259 patients (24,165 (54.6%) female; 25,562 (57.8%) estimated glomerular filtration (eGFR) 45–59 mL/1.73 m²) with CKD stages 3–5 were included. Nearly one-third of patients had diabetes and were more likely to have their blood pressure and albumin-to-creatinine ratio monitored than those without diabetes. Potentially appropriate prescribing of antihypertensives was achieved in 79.9% of hypertensive patients with CKD stages 4–5. The prescribing indicators for RAS inhibitors in patients with microalbuminuria and diabetes and in patients with macroalbuminuria were achieved in 69.9% and 62.3% of patients, respectively. Only 40.8% of patients with CKD and aged between 50 and 65 years were prescribed statin therapy. The prescribing of a RAS inhibitor plus a diuretic was less commonly achieved, with the indicator met in 20.6% for patients with microalbuminuria and diabetes and 20.4% for patients with macroalbuminuria. Potentially inappropriate prescribing of NSAIDs, metformin, and at least two RAS inhibitors were apparent in 14.3%, 14.1%, and 7.6%, respectively. Potentially inappropriate prescribing tended to be more likely in patients aged ≥65 years, living in regional or remote areas, or with socio-economic indexes for areas (SEIFA) score ≤ 3. Conclusions: We identified areas for possible improvement in the prescribing of RAS inhibitors and statins, as well as deprescribing of NSAIDs and metformin in Australian general practice patients with CKD.

An evaluation of general practice nurses' knowledge of chronic kidney disease risk factors and screening practices following completion of a case study-based asynchronous e-learning module

National and international guidelines recommend opportunistic screening for chronic kidney disease to allow for early detection and management. Despite these guidelines, screening for chronic kidney disease in general practice settings is often suboptimal. This paper reports the results of a study that evaluated: (a) the effect of an asynchronous web-based e-learning module on general practice nurses' knowledge about chronic kidney disease risk factors and screening practices; and (b) general practice nurses' perceived satisfaction with the e-learning module. Changes in chronic kidney disease knowledge were assessed using a pre-test and post-test evaluative design, and satisfaction scores were measured on completion of the module. Participants' baseline knowledge scores were poor, with mean pre-test scores of 3.77 (s.d. 1.66) out of 10. Post-test scores revealed a significant improvement (mean difference 1.81, (95% CI: 1.53 - 2.09), P < 0.01); however, overall final scores remained inadequate. Participants highly rated their satisfaction with the design of the module. Our results suggest that an asynchronous web-based e-learning module can improve general practice nurses' knowledge about chronic kidney disease risk factors and screening practice. Efforts are required to increase practice nurses' access to educational opportunities designed to improve knowledge in this area with the aim of increasing opportunistic screening for chronic kidney disease in the general practice setting.

Chronic kidney disease, Queensland: Profile of patients with chronic kidney disease from regional Queensland, Australia: A registry report

BACKGROUND

Chronic kidney disease, Queensland (CKD.QLD) is a multidisciplinary, collaborative research platform for CKD in Queensland. Most public renal services contribute towards the CKD Registry, including Toowoomba Hospital, which is a referral hospital for Darling Downs Health serving a largely regional population in Queensland. We aim to present the profile of the CKD cohort recruited to the CKD.QLD Registry from Toowoomba Hospital, the first comprehensive report on a pre-dialysis population from regional Australia.

METHODS

Study subjects were patients in the Darling Downs Health Service who consented to be included in the CKD.QLD registry from June 2011 to December 2016. Those who were on renal replacement therapy (RRT) were excluded. Patients were followed until date of RRT, death, discharge or loss to follow up or a censor date of 30th June 2017.

RESULTS

Overall 1051 subjects, representing 13% of all CKD.QLD Registry patients gave consent of whom, 42.7% were ≥70 years of age. The mean age was 63.8 ± 15.1 years (median age 67 years) with male predominance (55.4%). The majority were born in Australia (86.4%). Aboriginal and Torre Strait Islanders (A&TSI) constituted 9.6% of the cohort. The predominant CKD stages were 3b (28.9%) and 4 (27.7%). Hypertension and diabetes were noted in 91% and 44% of subjects, respectively. Diabetic nephropathy was the leading cause of CKD (26.7%) followed by renovascular disease (17.3%) and glomerulonephritis (14.8%). In 12%, the diagnosis was uncertain. Major co-morbidities included coronary artery disease (24.7%) chronic lung disease (14.8%), cerebrovascular disease (11.6%) and peripheral vascular disease (8.9%). Non-vascular co-morbidities included arthritis (24.6%), gout (23.6%) and gastro-oesophageal reflux disease (19%). The multi-morbidity profile was differed by gender, diabetic status and age. Over a follow-up period upto 72 months, 93 (8.8%) started RRT and 175 (16.6%) died. Of those 82% died without RRT and 18% died after RRT.

CONCLUSION

This CKD Registry cohort from regional Queensland consisted mainly of older Caucasians with male predominance. A&TSI patients were overrepresented compared to the overall population. A significant proportion had cardio-vascular disease and multiple co-morbidities which differed by gender, diabetic status and age. This report provides valuable data for health services planning and delivery in regional Queensland.

Primary care provider perceptions of enablers and barriers to following guideline-recommended laboratory tests to confirm chronic kidney disease: a qualitative descriptive study

Background

Patients should receive follow-up serum creatinine tests after an initial abnormal result to diagnose chronic kidney disease. However, half of the time this fails to occur in primary care. We interviewed primary care providers to better understand their perceptions of enablers and barriers to following this guideline-recommended care.

Methods

We performed a qualitative descriptive study guided by the Theoretical Domains Framework (TDF), a framework for behavioural change. We used purposeful sampling to recruit primary care providers (physicians and nurse practitioners) based on provider and practice characteristics (rural, solo versus team practice, etc.) from Ontario, Canada. We completed one-on-one interviews with providers using a semi-structured and open-ended interview guide based on the 14 TDF domains. We alternated between data collection and analysis, where we used directed content analysis to identify frequent, important, and conflicting enablers and barriers.

Results

We completed 13 interviews with nine primary care physicians and four nurse practitioners. Nine themes related to the TDF emerged from the data: 1) environmental context and resources, 2) knowledge, 3) memory, attention, and decision processes, 4) beliefs about consequences, 5) goals, 6) social or professional role, 7) behavioural regulation, 8) skills, and 9) optimism. Within these themes, we identified 16 enablers and five barriers. Some enablers included, providers’ knowledge on appropriate testing, their motivation to order these tests, and their use of tools and resources to help order follow-up serum creatinine tests. However, providers perceived some barriers including that ordering confirmatory laboratory tests for chronic kidney disease was not always a priority in regards to other care they wish to provide. Providers also noted that a perceived barrier is patients not going to the laboratory to complete the test.

Conclusions

We identified novel enablers and barriers to primary care providers completing guideline recommended repeat testing for the diagnosis of chronic kidney disease. Similar research is needed to understand the views of patients. These research findings can be used to inform strategies to improve the quality of care.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0879-2) contains supplementary material, which is available to authorized users.

Is there a correlation between an eGFR slope measured over a 5-year period and incident cardiovascular events in the following 5 years among a Flemish general practice population: a retrospective cohort study

OBJECTIVES

To examine if the estimated glomerular filtration rate (eGFR) slope over a 5-year period is related to incident cardiovascular (CV) events in the following 5 years.

DESIGN

Retrospective cohort study.

SETTING

Primary care.

PARTICIPANTS

All patients aged ≥50 years with at least four eGFR measurements between 01 January 2006 and 31 December 2010 were included in the study.

OUTCOME MEASURES

During the follow-up period (01 January 2011 until 31 December 2015), CV events (acute myocardial infarction, stroke (cerebrovascular accident (CVA)/transient ischemic attack (TIA)), peripheral arterial disease and acute heart failure) were identified.

METHODS

The slope was calculated by the least square method (in mL/min/year). The following slope categories were considered: (-1 to 1), (-3 to -1) (-5 to -3), ≤-5, (1 to 3), (3 to 5) and ≥5.00 mL/min/year. Cox proportional hazards model was used to assess the association between eGFR slope and incidence of CV events. Survival probability from CV events was estimated per slope category.

RESULTS

19 567 patients had at least four eGFR measurements, of whom 52% was female. 12% of the ≤-5 slope category developed a new CV event in comparison to 7.8% of the reference group and 5.4% of the ≥5 slope category. Survival rates were worst in those with a slope ≤-5. Patients with a slope of (-5 to -3) and ≤-5 had an adjusted HR of 1.37 and 1.55, respectively. Most patients with a slope <-3 mL/min had an eGFR still >60 mL/min.

CONCLUSIONS

Negative eGFR slopes of at least 3 mL/min/year give irrespectively of the eGFR itself a higher risk of CV events compared with patient groups with stable or improved kidney function. So the eGFR slope identifies an easy to define group of patients with a high risk for developing CV events.

Australian Community Pharmacists' Experience of Implementing a Chronic Kidney Disease Risk Assessment Service

Introduction

Community pharmacists are well positioned to deliver chronic kidney disease (CKD) screening services. However, little is known about the challenges faced by pharmacists during service implementation. This study aimed to explore community pharmacists’ experiences and perceived barriers of implementing a CKD risk assessment service.

Methods

Data collection was performed by using semistructured, open-ended interview questions. Pharmacists who had implemented a CKD screening service in Tasmania, Australia, were eligible to participate. A purposeful sampling strategy was used to select pharmacists, with variation in demographics and pharmacy location. A conventional content analysis approach was used to conduct the qualitative study. Transcripts were thematically analyzed by using the NVivo 11 software program. Initially, a list of free nodes was generated and data were coded exhaustively into relevant nodes. These nodes were then regrouped to form highly conceptualized themes.

Results

Five broad themes emerged from the analysis: contextual fit within community pharmacy; perceived scope of pharmacy practice; customer perception toward disease prevention; CKD – an underestimated disease; and remuneration for a beneficial service. Pharmacists found the CKD service efficient, user-friendly, and of substantial benefit to their customers. However, several pharmacists observed that their customers lacked interest in disease prevention, and had limited understanding of CKD. More importantly, pharmacists perceived the scope of pharmacy practice to depend substantially on interprofessional collaboration between pharmacists and general practitioners, and customer acknowledgment of pharmacists’ role in disease prevention.

Conclusion

Community pharmacists perceived the CKD service to be worth incorporating into pharmacy practice. To increase uptake, future CKD services should aim to improve customer awareness about CKD before providing risk assessment. Further research investigating strategies to enhance general practitioner involvement in pharmacist-initiated disease prevention services is also needed.

Evaluation of a chronic kidney disease risk assessment service in community pharmacies

AIM

Targeted 'opportunistic' screening might be a sustainable approach for the early detection of people with undiagnosed chronic kidney disease (CKD). The aim of this study was to implement and evaluate a CKD risk assessment service in the community pharmacy setting.

METHODS

Twenty-four pharmacies in Tasmania, Australia participated in this study. Targeted people were aged between 50 and 74 years, with at least one CKD risk factor. The QKidney risk calculator was used to estimate the participants' 5-year percentage risk of developing moderate-severe CKD. Participants identified with ≥3% risk were referred to their general practitioner (GP) and followed-up after 9 months. Laboratory data was collected from a pathology provider. The main outcome measures were rates of GP referral uptake and of participants who underwent estimated glomerular filtration rate (eGFR) and urine albumin creatinine ratio (ACR) measurement.

RESULTS

We analyzed data for 389 screened participants, of whom 203 (52.1%) had ≥3% 5-year risk of developing moderate-severe CKD and were referred to their GP. Follow-up was successful for 126 participants and showed low (27%) GP referral uptake. Analysis of the pathology data revealed suboptimal kidney testing in participants with ≥3% risk, with eGFR and ACR tests performed for only 52.7% and 25.1% of these participants, respectively.

CONCLUSIONS

There is significant scope for improving early detection of CKD via implementation of a community pharmacy-based CKD risk assessment service. However, a healthcare system that encourages inter-professional collaboration between community pharmacists and GPs, and provides a robust referral pathway is needed to optimize the effectiveness of this service.

eMAP:CKD: electronic diagnosis and management assistance to primary care in chronic kidney disease

Background

The increasing burden of chronic kidney disease (CKD) underpins the importance for improved early detection and management programs in primary care to delay disease progression and reduce mortality rates. eMAP:CKD is a pilot program for primary care aimed at addressing the gap between current and best practice care for CKD.

Methods

Customized software programs were developed to integrate with primary care electronic health records (EHRs), allowing real-time prompting for CKD risk factor identification, testing, diagnosis and management according to Kidney Health Australia's (KHA) best practice recommendations. Primary care practices also received support from a visiting CKD nurse and education modules. Patient data were analyzed at baseline (150 910 patients) and at 15 months (175 917 patients) following the implementation of the program across 21 primary care practices.

Results

There was improvement in CKD risk factor recognition (29.40 versus 33.84%; P < 0.001) and more complete kidney health tests were performed (3.20 versus 4.30%; P < 0.001). There were more CKD diagnoses entered into the EHR (0.48 versus 1.55%; P < 0.001) and more patients achieved KHA's recommended management targets (P < 0.001).

Conclusion

The eMAP:CKD program has shown an improvement in identification of patients at risk of CKD, appropriate testing and management of these patients, as well as increased documentation of CKD diagnosis entered into the EHRs. We have demonstrated efficacy in overcoming the verified gap between current and best practice in primary care. The success of the pilot program has encouraging implications for use across the primary care community as a whole.

CKD Screening and Surveillance in Australia: Past, Present, and Future

Chronic kidney disease (CKD) was largely a hidden health problem until the publication of an internationally agreed approach to its identification, monitoring, and treatment. The 2002 National Kidney Foundation CKD classification and the subsequent 2006 Kidney Disease Improving Global Outcomes (KDIGO) recommendations are powerful tools for translating thinking about CKD into clinical practice. These guidelines were strongly endorsed by the international community, including Australia, and were incorporated into CKD practice guidelines. In the past, CKD research studies in Australia focused on screening the general population, and more specifically, individuals at risk for CKD. Information from these studies led to the recognition that the CKD burden in Australia is a public health problem and contributed to the development of national health policies and priorities. At present, apart from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) that reports on CKD patients undergoing renal replacement therapy (RRT), long-term surveillance to describe the natural history of the CKD population not on RRT has only recently started. Entities such as CKD. Queensland and the Western Australian Nephrology Database are able to fill the gap and provide opportunities for collaborative research of CKD in Australia. Establishment of a National Health and Medical Research Centre-funded CKD Centre of Excellence in 2015 and the Better Evidence and Translation-Chronic Kidney Disease in 2016 are likely to change the future of CKD surveillance and research in Australia.

Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy

The global nephrology community recognises the need for a cohesive plan to address the problem of chronic kidney disease (CKD). In July, 2016, the International Society of Nephrology hosted a CKD summit of more than 85 people with diverse expertise and professional backgrounds from around the globe. The purpose was to identify and prioritise key activities for the next 5-10 years in the domains of clinical care, research, and advocacy and to create an action plan and performance framework based on ten themes: strengthen CKD surveillance; tackle major risk factors for CKD; reduce acute kidney injury-a special risk factor for CKD; enhance understanding of the genetic causes of CKD; establish better diagnostic methods in CKD; improve understanding of the natural course of CKD; assess and implement established treatment options in patients with CKD; improve management of symptoms and complications of CKD; develop novel therapeutic interventions to slow CKD progression and reduce CKD complications; and increase the quantity and quality of clinical trials in CKD. Each group produced a prioritised list of goals, activities, and a set of key deliverable objectives for each of the themes. The intended users of this action plan are clinicians, patients, scientists, industry partners, governments, and advocacy organisations. Implementation of this integrated comprehensive plan will benefit people who are at risk for or affected by CKD worldwide.

Closing the gap between evidence and practice in chronic kidney disease

There are major gaps between our growing knowledge of effective treatments for chronic kidney disease (CKD), and the delivery of evidence-based therapies to populations around the world. Although there remains a need for new, effective therapies, current evidence suggests that many patients with CKD are yet to fully realize the benefits of blood pressure-lowering drugs (with and without reducing proteinuria with renin-angiotensin system blockade), wider use of statins to reduce atherosclerotic cardiovascular disease events, and better glycemic control in both type 1 and type 2 diabetes. There are many barriers to optimizing evidence-based nephrology care around the world, including access to health care, affordability of treatments, consumer attitudes and circumstances, the dissemination of appropriate knowledge, the availability of expertise and structural impediments in the delivery of health care. Further investment in implementation science that addresses the major barriers to effective care in a cost-effective manner could yield both local and global benefits.

Quality of Care for Patients With Chronic Kidney Disease in the Primary Care Setting: A Retrospective Cohort Study From Ontario, Canada

BACKGROUND

Patients with chronic kidney disease may not be receiving recommended primary renal care.

OBJECTIVE

To use recently established primary care quality indicators for chronic kidney disease to determine the proportion of patients receiving recommended renal care.

DESIGN

Retrospective cohort study using administrative data with linked laboratory information.

SETTING

The study was conducted in Ontario, Canada, from 2006 to 2012.

PATIENTS

Patients over 40 years with chronic kidney disease or abnormal kidney function in primary care were included.

MEASUREMENTS

In total, 11 quality indicators were assessed for chronic kidney disease identified through a Delphi panel in areas of screening, monitoring, drug prescribing, and laboratory monitoring after initiating an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB).

METHODS

We calculated the proportion and cumulative incidence at the end of follow-up of patients meeting each indicator and stratified results by age, sex, cohort entry, and chronic kidney disease stage.

RESULTS

Less than half of patients received follow-up tests after an initial abnormal kidney function result. Most patients with chronic kidney disease received regular monitoring of serum creatinine (91%), but urine albumin-to-creatinine monitoring was lower (70%). A total of 84% of patients age 66 and older did not receive a non-steroidal anti-inflammatory drug prescription of at least 2-week duration. Three quarters of patients age 66 and older were on an ACE inhibitor or ARB, and 96% did not receive an ACE inhibitor and ARB concurrently. Among patients 66 to 80 years of age with chronic kidney disease, 65% were on a statin. One quarter of patients age 66 and older who initiated an ACE inhibitor or ARB had their serum creatinine and potassium monitored within 7 to 30 days.

LIMITATIONS

This study was limited to people in Ontario with linked laboratory information.

CONCLUSIONS

There was generally strong performance across many of the quality of care indicators. Areas where more attention may be needed are laboratory testing to confirm initial abnormal kidney function test results and monitoring serum creatinine and potassium after initiating a new ACE inhibitor or ARB.

Quality indicators for the detection and management of chronic kidney disease in primary care in Canada derived from a modified Delphi panel approach

BACKGROUND

The detection and management of chronic kidney disease lies within primary care; however, performance measures applicable in the Canadian context are lacking. We sought to develop a set of primary care quality indicators for chronic kidney disease in the Canadian setting and to assess the current state of the disease's detection and management in primary care.

METHODS

We used a modified Delphi panel approach, involving 20 panel members from across Canada (10 family physicians, 7 nephrologists, 1 patient, 1 primary care nurse and 1 pharmacist). Indicators identified from peer-reviewed and grey literature sources were subjected to 3 rounds of voting to develop a set of quality indicators for the detection and management of chronic kidney disease in the primary care setting. The final indicators were applied to primary care electronic medical records in the Electronic Medical Record Administrative data Linked Database (EMRALD) to assess the current state of primary care detection and management of chronic kidney disease in Ontario.

RESULTS

Seventeen indicators made up the final list, with 1 under the category Prevalence, Incidence and Mortality; 4 under Screening, Diagnosis and Risk Factors; 11 under Management; and 1 under Referral to a Specialist. In a sample of 139 993 adult patients not on dialysis, 6848 (4.9%) had stage 3 or higher chronic kidney disease, with the average age of patients being 76.1 years (standard deviation [SD] 11.0); 62.9% of patients were female. Diagnosis and screening for chronic kidney disease were poorly performed. Only 27.1% of patients with stage 3 or higher disease had their diagnosis documented in their cumulative patient profile. Albumin-creatinine ratio testing was only performed for 16.3% of patients with a low estimated glomerular filtration rate (eGFR) and for 28.5% of patients with risk factors for chronic kidney disease. Family physicians performed relatively better with the management of chronic kidney disease, with 90.4% of patients with stage 3 or higher disease having an eGFR performed in the previous 18 months and 83.1% having a blood pressure recorded in the previous 9 months.

INTERPRETATION

We propose a set of measurable indicators to evaluate the quality of the management of chronic kidney disease in primary care. These indicators may be used to identify opportunities to improve current practice in Canada.

Provision of care for chronic kidney disease by non-nephrologists in a developing nation: a national survey

OBJECTIVES

The prevalence of chronic kidney disease (CKD) in developing countries has increased dramatically. This study aimed to explore the practice patterns of non-dialysis-dependent CKD care in an affluent developing country.

SETTINGS

Primary and specialised healthcare facilities of public and private sectors in the United Arab Emirates.

PARTICIPANTS

159 non-nephrologist physicians practising in the United Arab Emirates.

INTERVENTIONS

A 28-item online self-administered questionnaire based on CKD clinical practice guidelines.

PRIMARY AND SECONDARY OUTCOME MEASURES

The physicians' approach to identifying and managing patients with CKD.

RESULTS

The survey was completed by 159 non-nephrologists, of whom 135 reported having treated patients with CKD. Almost all the respondents screen patients with hypertension and diabetes for CKD, but one-third of them do not screen patients with cardiovascular disease and elderly patients for CKD. The use of accurate CKD screening tests (estimated glomerular filtration rate and albumin/creatinine ratio) was suboptimal (77% and 59% of physicians used the procedures, respectively). One-third of the physicians do not offer treatment with inhibitors of the renin-angiotensin system to patients with CKD, and only 66% offer antilipid treatment. In general, the primary healthcare physicians are more familiar than secondary healthcare physicians with the diagnosis and management of patients with CKD.

CONCLUSIONS

We identified substantial physician-declared deficiencies in the practice of identifying and managing early CKD. Integration of quality CKD care within the healthcare system is required to face the increasing burden of CKD in the United Arab Emirates and possibly in other developing nations.

The influence of chronic kidney disease and age on revascularization rates and outcomes in acute myocardial infarction - a cohort study

BACKGROUND

There is a paucity of data on the complex interaction between chronic kidney disease, age and its impact on management and outcomes in acute myocardial infarction.

METHODS

A state based claims dataset that collects data on all hospitalizations (representing 32.3% of the Australian population) was used to identify all patients admitted with a principal diagnosis of acute myocardial infarction (ICD10 codes: I21.0-I21.4) over a four-year period. Patients were linked to the state death registry and followed until death or end of follow-up (31 December 2009). Chronic kidney disease was defined as the presence of any of 65 ICD10 diagnostic codes for chronic kidney disease. The primary outcomes were receipt of revascularization, length of hospital stay and mortality adjusted for age, comorbidities and prior revascularization at presentation.

RESULTS

Of the 40,472 patients with acute myocardial infarction, chronic kidney disease was present in 4814 patients (11.9%). Median follow-up was 2.8 years (range 0-5.5 years). In the multivariable model, there was a marked interaction between chronic kidney disease and age ( p<0.001). Chronic kidney disease was a powerful marker of lower revascularization rates (median age group of 70-79 years: odds ratio 0.68; 95% confidence interval 0.59-0.78; p<0.001), especially in those over the age of 50 years. The impact of chronic kidney disease on length of stay (median age group of 70-79 years vs. referent age group 18-39 years: incidence rate ratio 1.41; 95% confidence interval 1.32-1.51; p<0.001) and long-term mortality (median age group of 70-79 years: hazard ratio 2.19; 95% confidence interval 2.01-2.39; p<0.001) was mitigated with increasing age.

CONCLUSION

Chronic kidney disease is an important deterrent for the receipt of revascularization in older patients, but age is the primary determinant of length of stay and mortality.

Using Classification and Regression Trees (CART) to Identify Prescribing Thresholds for Cardiovascular Disease

BACKGROUND AND OBJECTIVE

Many guidelines for clinical decisions are hierarchical and nonlinear. Evaluating if these guidelines are used in practice requires methods that can identify such structures and thresholds. Classification and regression trees (CART) were used to analyse prescribing patterns of Australian general practitioners (GPs) for the primary prevention of cardiovascular disease (CVD). Our aim was to identify if GPs use absolute risk (AR) guidelines in favour of individual risk factors to inform their prescribing decisions of lipid-lowering medications.

METHODS

We employed administrative prescribing information that is linked to patient-level data from a clinical assessment and patient survey (the AusHeart Study), and assessed prescribing of lipid-lowering medications over a 12-month period for patients (n = 1903) who were not using such medications prior to recruitment. CART models were developed to explain prescribing practice. Out-of-sample performance was evaluated using receiver operating characteristic (ROC) curves, and optimised via pruning.

RESULTS

We found that individual risk factors (low-density lipoprotein, diabetes, triglycerides and a history of CVD), GP-estimated rather than Framingham AR, and sociodemographic factors (household income, education) were the predominant drivers of GP prescribing. However, sociodemographic factors and some individual risk factors (triglycerides and CVD history) only become relevant for patients with a particular profile of other risk factors. The ROC area under the curve was 0.63 (95% confidence interval [CI] 0.60-0.64).

CONCLUSIONS

There is little evidence that AR guidelines recommended by the National Heart Foundation and National Vascular Disease Prevention Alliance, or conditional individual risk eligibility guidelines from the Pharmaceutical Benefits Scheme, are adopted in prescribing practice. The hierarchy of conditional relationships between risk factors and socioeconomic factors identified by CART provides new insights into prescribing decisions. Overall, CART is a useful addition to the analyst's toolkit when investigating healthcare decisions.

Perceptions of prognostic risks in chronic kidney disease: a national survey

Background

Predicting the clinical trajectories of chronic kidney disease (CKD) to discern personalized care remains a complex challenge in nephrology. Understanding the appropriate risk thresholds and time frame associated with predicting risks of key outcomes (kidney failure, cardiovascular (CV) events, and death) is critical in facilitating decision-making. As part of an exploratory research and practice support needs assessment, we aimed to determine the importance of the time frames for predicting key outcomes, and to assess the perceived demand for risk prediction tools among Canadian nephrologists.

Methods

A web-based survey was developed by a pan-Canadian expert panel of practitioners. Upon pre-test for clarity and ease of completion, the final survey was nationally deployed to Canadian nephrologists. Anonymous responses were gathered over a 4-month period. The results were analyzed using descriptive statistics.

Results

One hundred eleven nephrologists responded to our survey. The majority of the respondents described prediction of events over time frames of 1–5 years as being “extremely important” or “very important” to decision-making on a 5-point Likert scale. To plan for arteriovenous fistula referral, the respondents deemed thresholds which would predict probability of kidney failure between >30 and >50 % at 1 year, as useful, while many commented that the rate of progression should be included for decision-making. Over 80 % of the respondents were not satisfied with their current ability to predict the progression to kidney failure, CV events, and death. Most of them indicated that they would value and use validated risk scores for decision-making.

Conclusions

Our national survey of nephrologists shows that the risk prediction for major adverse clinical outcomes is valuable in CKD at multiple time frames and risk thresholds. Further research is required in developing relevant and meaningful risk prediction models for clinical decision-making in patient-centered CKD care.

Electronic supplementary material

The online version of this article (doi:10.1186/s40697-015-0088-z) contains supplementary material, which is available to authorized users.

Implementation of the KDIGO guideline on lipid management requires a substantial increase in statin prescription rates

The KDIGO guideline on lipid management in adult patients with chronic kidney disease (CKD) reflects a paradigm shift as proposals for statin use are based on cardiovascular risk rather than cholesterol levels. Statin use is now universally recommended in CKD patients 50 years and older, assuming a 10-year risk of coronary heart disease (CHD) of over 10%. Specific comorbidities or formal risk calculation are required for younger patients. It is unknown to which extent these new guidelines differ from previous practice. Here we analyzed statin use in the German Chronic Kidney Disease study of 5217 adult patients with moderately severe CKD under nephrological care enrolled shortly before publication of the new guideline. Accordingly, 407 patients younger than 50 years would be eligible for statins compared with the 277 patients treated so far, and all 4224 patients 50 years and older would be eligible compared with the 2196 already treated. Overall, guideline implementation would almost double statin prescription from 47 to 88%. Among patients 50 years and older currently not on a statin, an estimated 10-year CHD and atherosclerotic event risks over 10% were present in 68% and 82%, respectively. Thus, implementation of the new lipid guideline requires a substantial change in prescription practice, even in CKD patients under nephrological care. Based on comorbidities and risk estimates, the universal recommendation for statin use in CKD patients 50 years and older appears justified.

Early chronic kidney disease: diagnosis, management and models of care

Chronic kidney disease (CKD) is prevalent in many countries, and the costs associated with the care of patients with end-stage renal disease (ESRD) are estimated to exceed US$1 trillion globally. The clinical and economic rationale for the design of timely and appropriate health system responses to limit the progression of CKD to ESRD is clear. Clinical care might improve if early-stage CKD with risk of progression to ESRD is differentiated from early-stage CKD that is unlikely to advance. The diagnostic tests that are currently used for CKD exhibit key limitations; therefore, additional research is required to increase awareness of the risk factors for CKD progression. Systems modelling can be used to evaluate the impact of different care models on CKD outcomes and costs. The US Indian Health Service has demonstrated that an integrated, system-wide approach can produce notable benefits on cardiovascular and renal health outcomes. Economic and clinical improvements might, therefore, be possible if CKD is reconceptualized as a part of primary care. This Review discusses which early CKD interventions are appropriate, the optimum time to provide clinical care, and the most suitable model of care to adopt.

Early mortality in dialysis and adequacy of predialysis renal care: the picture is more complex than we thought

Two new studies examine clinical events during early dialysis. Foley et al. underline a probable ascertainment bias affecting the mortality rate during the first 6 weeks and find that age is the major risk factor for very early mortality, which can be amplified by short time of predialysis nephrology care. Singhal et al. show that adequacy of predialysis renal care is determined not only by the timing of the nephrology referral but also by the number and timing of visits.

Chronic kidney disease in general populations and primary care: diagnostic and therapeutic considerations

PURPOSE OF REVIEW

The majority of people with chronic kidney disease (CKD) are managed by primary care physicians and nurses, but much of the initial research on CKD care was based in secondary care. The purpose of this article is to review the important recent studies of CKD in primary care that are starting to provide an evidence base for the strategies to improve the management and outcomes of the unreferred majority of people with CKD.

RECENT FINDINGS

People with CKD in primary care populations differ substantially from those familiar to nephrologists in secondary care by being older, having less reduction in glomerular filtration rate (GFR) and lower prevalence of proteinuria. These differences have important implications for management priorities. Detailed studies have identified widespread deficiencies in the care of patients with CKD in primary care (though these are also reported in secondary care). Interventions that may improve performance include automated reporting of estimated GFR, incentivizing primary care practitioners to achieve therapeutic goals and quality improvement strategies such as audit-based education.

SUMMARY

Studies have identified a need for improved management of CKD in primary care as well as methods to achieve this. Future studies should focus on the promotion of self-management through telemedicine and the Internet.

[Intravenous iron during predialysis period improves anemia management and cardiovascular parameters in incident hemodialysis patients]

Individualized use of iron therapy (IT) and erythropoiesis-stimulating agents (ESA) may effectively correct anemia and its symptoms in CKD patients (Pts). The aim of this retrospective study was to precise the anemia management (AM) in incident HD Pts, and to compare Pts treated by intravenous (i.v.) IT and ESA during predialysis to those treated by oral IT and ESA on AM and cardiovascular parameters during the first year of HD. One hundred and two Pts performed their first dialysis in the unit, mean age 58.5 (15.9) years, 70% males, 27% diabetes. Ninety Pts started with a native arteriovenous fistula. Charlson comorbidity index was 7.3 (3.5). Mortality rate was 3% at one year. Hb level was at start 10.6 (1.7) and at one year 11.7 (1.1) g/dL (P<0.0001). DA injected every 2weeks was at the beginning at 107 (56) μg and then at 61 (46) (P<0.0001). i.v. IT injected every week was at the dosage of 87 (23) mg and then at 57 (40mg) per injection (P<0.001). Out of 102 Pts, 33 received i.v. IT during predialysis. These Pts started dialysis with a better Hb level: 11.1 (1.3) versus 10.4 (1.55) g/dL (P<0.01), had a TSAT at 50.0 (19.2) versus 30.1 (15.2) % (P<0.001), received less ESA 0.58 (0.28) versus 0.82 (0.37) μg/kg per week (P<0.01). More important were the changes on the cardiovascular functions: left ventricular mass at 116 (34) versus 134 (39) g/m(2) (P<0.02), left ventricular ejection fraction at 64.7 (4.4) versus 61.4 (8.7) % (P<0.02) and mean arterial pressure at 104.7 (80) versus 109 (13.2) mmHg (P<0.02). These Pts were also less hospitalized. This study revealed the importance of i.v. IT during predialysis care not only on AM but also on cardiovascular status in HD Pts starting dialysis.

Documentation and management of CKD in rural primary care

BACKGROUND AND OBJECTIVES

Recognition of CKD by primary care practitioners is essential in rural communities where nephrology access is limited. This study determined the prevalence of undocumented CKD in patients cared for in rural primary care practices and evaluated characteristics associated with undocumented CKD as well as CKD management.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A retrospective cohort study, conducted within the Oregon Rural Practice Based Research Network, consisted of 865 CKD patients with serum creatinine≥1.5 mg/dl in males and ≥1.3 mg/dl in females and an estimated GFR<60 ml/min per 1.73 m(2). Documentation of a CKD diagnosis and laboratory values were abstracted by chart review.

RESULTS

Of CKD patients, 51.9% had no documentation of CKD. Undocumented CKD occurred more frequently in female patients (adjusted odds ratio=2.93, 95% confidence interval=2.04, 4.21). The association of serum creatinine reporting versus automating reporting of estimated GFR on CKD documentation was dependent on patient sex, years of practitioner experience, and practitioner clinical training. Hypertensive patients with documented CKD were more likely to have a BP medication change than patients with undocumented CKD (odds ratio=2.07, 95% confidence interval=1.15, 3.73). Only 2 of 449 patients with undocumented CKD were comanaged with a nephrologist compared with 20% of patients with documented CKD (odds ratio=53.20, 95% confidence interval=14.90, 189.90).

CONCLUSIONS

Undocumented CKD in a rural primary care setting is frequent, particularly in female patients. Depending on practitioner characteristics, automatic reporting of estimated GFR might improve documentation of CKD in this population.

Nephrologist follow-up improves all-cause mortality of severe acute kidney injury survivors

Survivors of severe acute kidney injury remain at high risk of death well after apparent recovery from the initial insult. Here we determine whether early nephrology follow-up after a hospitalization complicated by severe acute kidney injury associates with patient survival. This consisted of a cohort study of all hospitalized adults in Ontario from 1996 to 2008 with acute kidney injury who received temporary inpatient dialysis and survived for 90 days following discharge independent from dialysis. Propensity scores were used to match individuals with early nephrology follow-up, defined as a visit with a nephrologist within 90 days of discharge, to those without. The outcome was time to all-cause mortality of 3877 patients who met the eligibility criteria within a maximum follow-up of 2 years. A total of 1583 patients had early nephrology follow-up of whom 1184 were successfully matched 1:1 to those not receiving early follow-up. The incidence of all-cause mortality was lower in those patients with early nephrology follow-up compared with those without (8.4 compared with 10.6 per 100-patient years, hazard ratio 0.76 (95% CI: 0.62-0.93)). Thus, early nephrology follow-up after hospitalization with acute kidney injury and temporary dialysis was associated with improved survival. This finding requires definitive testing in a randomized controlled trial.

Statins and kidney disease: is the study of heart and renal protection at the cutting edge of evidence?

PURPOSE OF REVIEW

Dyslipidaemias are noted in all stages of chronic kidney disease (CKD). Currently most evidence for their treatment comes from secondary retrospective analyses of patient subgroups with CKD recruited into clinical trials powered of hypertensive and dyslipideamic cohorts powered for cardiovascular endpoints.These analyses suggest a number of different beneficial effects of statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) on renal, cardiovascular and mortality outcomes. However, there is disagreement on the impact of interventions at different CKD stages, and on treatment targets.

RECENT FINDINGS

The Study of Heart and Renal Protection (SHARP) trial published in June 2011 was the first trial specifically powered to investigate atherosclerotic outcomes in CKD patients. It found a 17% overall reduction in major adverse cardiac events in the statin-treated group compared with placebo, yet no effect on any renal outcomes of proteinuria and progressive decline of glomerular filtration rate. Furthermore, the Swedish Web-system for Enhancement and Development of Evidencebased care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) investigators provided further important observational data on the beneficial effect of statins in CKD stages I-IV.

SUMMARY

The evidence that statins have a cardiovascular and mortality benefit in CKD stages I-IV has been reinforced by SHARP, which also definitively shows that there are no special safety concerns for their administration in CKD. However, the utility of the use of statins in patients on dialysis is far from clear, at least in our opinion. The effect of statins on renal outcomes is unconvincing and the evidence does not presently support their use for these indications alone.