Prevalence and management of chronic kidney disease in primary care patients in the UK

Obstacles and Opportunities for Albuminuria Testing On the Basis of the Perspective of Primary Care: A Qualitative Study

Key Points

Pay-for-performance indicators and lack of knowledge about new drugs limit general practitioners' ability to identify target populations and perform urinary protein assays. Choosing between several possible assays is associated with confusion and exposes general practitioners to the risk of inappropriate referrals to nephrologists. Revising pay-for-performance indicators, drafting multidisciplinary guidelines, raising multiprofessional collaboration, and patient awareness should be considered.

Background

Albuminuria testing is an easy way to identify, early on, a higher risk of cardiovascular and kidney morbidity and mortality in patients at risk. In France, the urine albumin-to-creatinine ratio is an indicator for Remuneration for Public Health Objectives (primary care pay-for-performance) for patients with diabetes or hypertension. These tests must be performed annually by General Practitioners (GPs), but are not sufficiently performed, although drug therapies depend on them. We wanted to understand the practice of urinary protein screening assays by means of a qualitative study on the experience of GPs in a French region, with a view to developing facilitating strategies.

Methods

This qualitative, semiopragmatic, phenomenological study analyzed in-depth interviews held with a purposive sample (age, sex, training, type of practice, rural/urban context) of 27 GPs, with triangulation of researchers until data saturation.

Results

GPs recognized the assay as a systematic screening tool in accordance with the guidelines, but limited it to patients with diabetes or hypertension encouraged by primary care pay-for-performance. Noting that their intervention was limited to kidney-protective measures already in place and, unaware of the new drugs, they saw no benefits and considered it a nonpriority test. The existence of several urinary assays with varying intervention thresholds, changes in guidelines, and the fact that specialists in laboratory medicine can decide which test to use depending on reimbursement by the health insurance scheme, all contributed to GPs' confusion in prescribing and interpreting tests. One consequence of this was inappropriate referral to the nephrologist. These tests required them to adopt a patient-centered educational approach, making it difficult for certain patients to perform them.

Conclusions

GPs were aware of guideline recommendations to screen for albuminuria in patients with diabetes and hypertension but had difficulty interpreting the results. Their lack of perceived clinical consequences and new drugs should be targeted to improve the situation.

KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease in Children and Adults: a commentary from the European Renal Best Practice (ERBP)

The Kidney Disease: Improving Global Outcomes (KDIGO) 2024 Guideline for Identification and Management of Chronic Kidney Disease (CKD) is a welcome development, coming 12 years after the paradigm-changing 2012 guidelines. We are living in an unprecedented era in nephrology with novel therapies, including sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists, now being proven in multiple randomized controlled clinical trials to reduce both the progression of CKD and cardiovascular morbidity and mortality. The KDIGO 2024 CKD Guideline is aimed at a broad audience looking after children and adults with CKD and provide practical and actionable steps to improve care. This commentary reviews the guideline sections pertaining to the evaluation and risk assessment of individuals with CKD from a European perspective. We feel that despite the last guideline being published 12 years ago, and the fact that the assessment of CKD has been emphasized by many other national/international nephrology, cardiology and diabetology guidelines and societies, the diagnosis and treatment of CKD remains poor across Europe. As such, the KDIGO 2024 CKD Guideline should be seen as an urgent call to action to improve diagnosis and care of children and adults with CKD across Europe. We know what we need to do. We now need to get on and do it.

Sex-specific temporal trends in incidence and prevalence of chronic kidney disease: a Danish population-based cohort study

Background

Rates of chronic kidney disease (CKD) may change with ageing populations, rising metabolic and cardiovascular disease prevalence, increasing CKD awareness and new treatments. We examined sex-specific temporal trends in CKD incidence and prevalence from 2011 through 2021.

Methods

We conducted a population-based cohort study among adults residing in the North and Central Denmark Regions (population ∼1.5 million in 2021), utilizing routinely collected individual-level laboratory data. We identified individuals with incident or prevalent CKD, using data on plasma creatinine and urine albumin-creatinine ratios from samples performed in outpatient hospital settings or primary care. We estimated annual sex-specific crude and age-standardized incidence and prevalence and tabulated clinical characteristics.

Results

Throughout 2011-2021, CKD incidence and prevalence remained higher among females than males. A transient increase in the crude incidence was observed during 2011-2013, followed by a decrease from 11.8 per 1000 person-years in 2013 [95% confidence interval (CI) 11.5-12.1] to 10.7 in 2021 (95% CI 10.5-11.0) among females and from 10.9 (95% CI 10.7-11.2) to 10.6 (95% CI 10.3-10.8) among males. During 2011-2021, the crude prevalence increased among females from 85.1 per 1000 individuals (95% CI 84.4-85.8) to 99.9 (95% CI 99.2-100.6), and among males from 55.3 (95% CI 54.7-55.9) to 82.4 (95% CI 81.8-83.0). After age standardization, declines in incidence persisted, while the prevalence was stable among females, and the increase persisted among males.

Conclusions

The CKD incidence and prevalence remained higher among females than males during 2011-2021. Despite a notable decline in incidence rates from 2013 onwards, the crude prevalence increased during 2011-2021.

Kidney failure amongst Irish Travellers

BACKGROUND

The occurrence of Kidney Failure with Replacement Therapy (KFRT) amongst Irish Travellers has not been well described. This study aims to determine the burden of KFRT amongst the Irish Traveller population and identify determinants of health amongst this cohort which may differ from the general population in Ireland.

METHODS

This retrospective cohort study included self-identifying Irish Travellers with KFRT registered in the National Kidney Disease Clinical Patient Management System between 1995 and 2022. KFRT was defined as Chronic Kidney Disease stage 5 (CKD G5) treated by dialysis or CKD G1-G5 after transplantation. The primary outcome measure was the prevalence of KFRT in Irish Travellers. Secondary exploratory outcomes included age at diagnosis, family history, biopsy diagnosis, kidney replacement therapy (KRT) modality, time to initiation of KRT, primary vascular access used, and time to receive a kidney transplant.

RESULTS

Four of six Irish hospital groups participated in the study. A total of 38 patients were identified as Irish Travellers with KFRT, with a crude prevalence rate of KFRT of 0.12% (CI 0.084-0.161, 95%) or 11.9 per 10,000 Irish Travellers. The mean age for diagnosis of kidney disease was 43 (SD, 20.8) and at commencement of KRT was 45 (SD, 20.9) years. A biopsy-proven diagnosis was provided in 24%. Twenty-two per cent was diagnosed with polycystic kidney disease or congenital anomalies of the kidney and urinary tract. The predominant modality for KRT was haemodialysis (89%), with central venous catheters being the most common initial vascular access (79%). Kidney transplants occurred in 45% of those studied, with a mean waiting time of 1.96 (SD, 1.6) years.

CONCLUSIONS

The Irish Traveller community have similar prevalence of KFRT when compared to the national prevalence, with a short time interval from diagnosis to commencement of KRT. They are less likely to avail of home therapies but have comparable wait times to the national waiting time to receive a kidney transplant.

The estimation of glomerular filtration in acute and critical illness: Challenges and opportunities

Recent events have made it apparent that the creatinine based estimating equations for glomerular filtration have their flaws. Some flaws have been known for some time; others have prompted radical modification of the equations themselves. These issues persist in part owing to the behaviour of the creatinine molecule itself, particularly in acute and critical illness. There are significant implications for patient treatment decisions, including drug and fluid therapies and choice of imaging modality (contrast vs. non-contrast CT scan for example). An alternative biomarker, Cystatin C, has been used with some success both alone and in combination with creatinine to help improve the accuracy of particular estimating equations. Problems remain in certain circumstances and costs may limit the more widespread use of the alternative assay. This review will explore both the historical and more recent evidence for glomerular filtration estimation, including options to directly measure glomerular filtration (rather than estimate), perhaps the holy grail for both Biochemistry and Nephrology.

Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes

BACKGROUND

CKD affects 850 million people worldwide and is associated with high risk of kidney failure and death. Existing, evidence-based treatments are not implemented in at least a third of eligible patients, and there is socioeconomic inequity in access to care. While interventions aiming to improve delivery of evidence-based care exist, these are often complex, with intervention mechanisms acting and interacting in specific contexts to achieve desired outcomes.

METHODS

We undertook realist synthesis to develop a model of these context-mechanism-outcome interactions. We included references from two existing systematic reviews and from database searches. Six reviewers produced a long list of study context-mechanism-outcome configurations based on review of individual studies. During group sessions, these were synthesized to produce an integrated model of intervention mechanisms, how they act and interact to deliver desired outcomes, and in which contexts these mechanisms work.

RESULTS

Searches identified 3371 relevant studies, of which 60 were included, most from North America and Europe. Key intervention components included automated detection of higher-risk cases in primary care with management advice to general practitioners, educational support, and non-patient-facing nephrologist review. Where successful, these components promote clinician learning during the process of managing patients with CKD, promote clinician motivation to take steps toward evidence-based CKD management, and integrate dynamically with existing workflows. These mechanisms have the potential to result in improved population kidney disease outcomes and cardiovascular outcomes in supportive contexts (organizational buy-in, compatibility of interventions, geographical considerations). However, patient perspectives were unavailable and therefore did not contribute to our findings.

CONCLUSIONS

This systematic review and realist synthesis describes how complex interventions work to improve delivery of CKD care, providing a framework within which future interventions can be developed. Included studies provided insight into the functioning of these interventions, but patient perspectives were lacking in available literature.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_05_08_CJN0000000000000136.mp3.

Sex Differences in the Recognition, Monitoring, and Management of CKD in Health Care: An Observational Cohort Study

INTRODUCTION

Reported sex differences in the etiology, population prevalence, progression rates, and health outcomes of people with CKD may be explained by differences in health care.

METHODS

We evaluated sex as the variable of interest in a health care-based study of adults (n=227,847) with at least one outpatient eGFR<60 ml/min per 1.73 m2 measurement denoting probable CKD in Stockholm from 2009 to 2017. We calculated the odds ratios for diagnosis of CKD and provision of RASi and statins at inclusion, and hazard ratios for CKD diagnosis, visiting a nephrologist, or monitoring creatinine and albuminuria during follow-up.

RESULTS

We identified 227,847 subjects, of whom 126,289 were women (55%). At inclusion, women had lower odds of having received a diagnostic code for CKD and were less likely to have received RASi and statins, despite having guideline-recommended indications. In time-to-event analyses, women were less likely to have received a CKD diagnosis (HR, 0.43; 95% CI, 0.42 to 0.45) and visited a nephrologist (HR, 0.46; 95% CI, 0.43 to 0.48) regardless of disease severity, presence of albuminuria, or criteria for referral. Women were also less likely to undergo monitoring of creatinine or albuminuria, including those with diabetes or hypertension. These differences remained after adjustment for comorbidities, albuminuria, and highest educational achievement, and among subjects with confirmed CKD at retesting. Although in absolute terms all nephrology-care indicators gradually improved over time, the observed sex gap persisted.

CONCLUSIONS

There were profound sex differences in the detection, recognition, monitoring, referrals, and management of CKD. The disparity was also observed in people at high risk and among those who had guideline-recommended indications.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2022_10_11_JASN2022030373.mp3.

Comparison of the 2013 and 2019 Nationwide Surveys on the Management of Chronic Kidney Disease by General Practitioners in Japan

In 2019, the Japan Physicians Association conducted a second nationwide survey on the management of chronic kidney disease (CKD) among the Japanese general practitioners (GPs). We aimed to clarify the changes in the state of CKD medical care by GPs since the 2013 survey. The 2013 and 2019 surveys included 2214 and 601 GPs, respectively, who voluntarily participated. The two surveys were compared, using propensity score matching to balance the background of the responded GPs. For the medical care of CKD, the frequency of urine or blood examination, use of estimated glomerular filtration rate (eGFR) value for CKD management, and continuous use of renin-angiotensin system inhibitors for their reno-protective effects were significantly higher in 2019 than in 2013 (all: p < 0.001). The medical cooperation in CKD management, the utilization of the clinical path for CKD management and the measurement of the eGFR during the medical health checkup were significantly increased in 2019, compared to those in 2013. More GPs felt dissatisfied with the components of CKD treatment by nephrologists (p < 0.001). The two surveys confirmed improvements in the level of medical care for CKD and a strengthening in cooperation. However, the dissatisfaction with the consultation with nephrologists did not necessarily improve.

Treatment and prescribing trends of antihypertensive drugs in 2.7 million UK primary care patients over 31 years: a population-based cohort study

OBJECTIVES

To describe the prescribing trends of antihypertensive drugs in primary care patients and assess the trajectory of antihypertensive drug prescriptions, from first-line to third-line, in patients with hypertension according to changes to the United Kingdom (UK) hypertension management guidelines.

DESIGN

Population-based cohort study.

SETTING AND PARTICIPANTS

We used the UK Clinical Practice Research Datalink, an electronic primary care database representative of the UK population. Between 1988 and 2018, we identified all adult patients with at least one prescription for a thiazide diuretic, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta-blocker or calcium channel blocker (CCB).

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated the period prevalence of patients with antihypertensive drug prescriptions for each calendar year over a 31-year period. Treatment trajectory was assessed by identifying patients with hypertension newly initiating an antihypertensive drug, and treatment changes were defined by a switch or add-on of a new class. This cohort was stratified before and after 2007, the year following important changes to UK hypertension management guidelines.

RESULTS

The cohort included 2 709 241 patients. The prevalence of primary care patients with antihypertensive drug prescriptions increased from 7.8% (1988) to 21.9% (2018) and was observed for all major classes except thiazide diuretics. Patients with hypertension initiated thiazide diuretics (36.8%) and beta-blockers (23.6%) as first-line drugs before 2007, and ACE inhibitors (39.9%) and CCBs (31.8%) after 2007. After 2007, 17.3% were not prescribed guideline-recommended first-line agents. Overall, patients were prescribed a median of 2 classes (IQR 1-2) after first-line treatment.

CONCLUSION

Nearly one-quarter of primary care patients were prescribed antihypertensive drugs by the end of the study period. Most patients with hypertension initiated guideline-recommended first-line agents. Not all patients, particularly females, were prescribed recommended agents however, potentially leading to suboptimal cardiovascular outcomes. Future research should aim to better understand the implication of this finding.

[Non-dialysis chronic kidney disease in primary care - a questionnaire study among general practitioners]

BACKGROUND

The majority of patients with non-dialysis chronic kidney disease are cared for by general practitioners. Especially for Germany, the evidence of this topic is still very low. The aim of the survey was to estimate the perceived frequency of non-dialysis chronic kidney disease in general practice, the use of diagnostics and therapy, used tools considering the professional background and experience of the responding general practitioners.

METHODS

A questionnaire was self-designed in the cooperation of several disciplines. 1130 general practitioners from Saxony and Saxony-Anhalt were randomly selected and the questionnaire was sent by post. Data were collected from June 2019 to July 2019.

RESULTS

Of the 1,130 questionnaires sent, 372 returned analysable (response rate: 32.9 %). The prevalence of non-dialysis chronic kidney disease was estimated to be 6-15 %. 97 % of the general practitioners rated the adjustment of high blood pressure and diabetes mellitus as a high to very high priority. Concerning the diagnosis of proteinuria, the use of a urine dipstick test was stated by 60.8 % of the respondents and the requirement for an albumin/creatinine-ratio was stated by 22.6 %. Only a few differences could be revealed in the response behavior of the participating groups of doctors. Working experience is an important factor in choosing tools, especially guidelines.

CONCLUSIONS

The results showed that the doctors interviewed followed international recommendations for the care of patients with non-dialysis chronic kidney disease. However, improvements in progression diagnostics are necessary and important. General practitioners and internal medicines working as general practitioners have a comparable level of competence in the primary medical care of the non-dialysis chronic kidney disease. Significant differences were created by the professional experience of the doctors.

KEY POINTS

· General practitioners estimate the prevalence of non-dialysis chronic kidney disease in their practice at 6-15 %.. · Using the albumin/creatinine-ratio for proteinuria diagnostics is requested too rarely compared to the urine dipstick test.. · General practitioners, specialists in general medicine and internists working in general medicine have a comparable level of competence to treat patients with non-dialysis chronic kidney disease.. · Working experience is an important factor in choosing tools, especially guidelines..

Prevalence and factors associated with multimorbidity among primary care patients with decreased renal function

Objectives

To establish the prevalence of multimorbidity in people with chronic kidney disease (CKD) stages 1–5 and transiently impaired renal function and identify factors associated with multimorbidity.

Design and setting

Prospective cohort study in UK primary care.

Participants

861 participants aged 60 and older with decreased renal function of whom, 584 (65.8%) had CKD and 277 (32.2%) did not have CKD.

Interventions

Participants underwent medical history and clinical assessment, and blood and urine sampling.

Primary and secondary outcome measures

Multimorbidity was defined as presence of ≥2 chronic conditions including CKD. Prevalence of each condition, co-existing conditions and multimorbidity were described and logistic regression was used to identify predictors of multimorbidity.

Results

The mean (±SD) age of participants was 74±7 years, 54% were women and 98% were white. After CKD, the next most prevalent condition was hypertension (n = 511, 59.3%), followed by obesity (n = 265, 30.8%) ischemic heart disease (n = 145, 16.8%) and diabetes (n = 133, 15.4%). Having two co-existing conditions was most common (27%), the most common combination of which was hypertension and obesity (29%). One or three conditions was the next most prevalent combination (20% and 21% respectively). The prevalence of multimorbidity was 73.9% (95%CI 70.9–76.8) in all participants and 86.6% (95%CI 83.9–89.3) in those with any-stage CKD. Logistic regression found a significant association between increasing age (OR 1.07, 95%CI 1.04–0.10), increasing BMI (OR 1.15, 95%CI 1.10–1.20) and decreasing eGFR (OR 0.99, 95%CI 0.98–1.00) with multimorbidity.

Conclusions

This analysis is the first to provide an accurate estimate of the prevalence of multimorbidity in a screened older primary care population living with or at risk of CKD across all stages. Hypertension and obesity were the most common combination of conditions other than CKD that people were living with, suggesting that there may be multiple reasons for closely monitoring health status in individuals with CKD.

The risk of new fragility fractures in patients with chronic kidney disease and hip fracture-a population-based cohort study in the UK

Chronic kidney disease (CKD) is a risk factor for fractures. However, in hip fracture patients, CKD G3-G5 was associated with a higher mortality risk and not associated with a higher risk of subsequent non-hip fractures compared to eGFR > 60 ml/min. The higher mortality risk may, as competing risk, explain our findings.

INTRODUCTION

Chronic kidney disease (CKD) is a known risk factor for fragility fractures. Patients aged 50+ with a recent fragility fracture have an increased risk of subsequent fractures. Our aim was to evaluate the association between CKD stages G3-G5 versus estimated glomerular filtration rate (eGFR) > 60 ml/min and the risk of a new non-hip fracture or fragility fracture in patients with a first hip fracture.

METHODS

Population-based cohort study using the UK general practices in the Clinical Practice Research Datalink. Associations between CKD stage and first subsequent fracture were determined using Cox proportional hazard analyses to estimate hazard ratios (HRs). To explore the potential competing risk of mortality, cause-specific (cs) HRs for mortality were estimated.

RESULTS

CKD G3-G5 was associated with a lower risk of any subsequent non-hip fracture (HR: 0.90, 95%CI: 0.83-0.97), but not with the risk of subsequent major non-hip fragility fracture. CKD G3-G5 was associated with a higher mortality risk (cs-HR: 1.05, 95%CI: 1.01-1.09). Mortality risk was 1.5- to 3-fold higher in patients with CKD G4 (cs-HR: 1.50, 95%CI: 1.38-1.62) and G5 (cs-HR: 2.93, 95%CI: 2.48-3.46) compared to eGFR > 60 ml/min.

CONCLUSIONS

The risk of a subsequent major non-hip fragility fractures following hip fracture was not increased in patients with CKD G3-G5 compared to eGFR > 60 ml/min. Mortality risk was higher in both hip fracture and non-hip fracture patients with CKD G4 and G5. The higher mortality risk may, as competing risk, explain our main finding of no increased or even decreased subsequent fracture risk after a hip fracture in patients with CKD G3-G5.

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.

How do primary care doctors in England and Wales code and manage people with chronic kidney disease? Results from the National Chronic Kidney Disease Audit

Background

In the UK, primary care records are electronic and require doctors to ascribe disease codes to direct care plans and facilitate safe prescribing. We investigated factors associated with coding of chronic kidney disease (CKD) in patients with reduced kidney function and the impact this has on patient management.

Methods

We identified patients meeting biochemical criteria for CKD (two estimated glomerular filtration rates <60 mL/min/1.73 m² taken >90 days apart) from 1039 general practitioner (GP) practices in a UK audit. Clustered logistic regression was used to identify factors associated with coding for CKD and improvement in coding as a result of the audit process. We investigated the relationship between coding and five interventions recommended for CKD: achieving blood pressure targets, proteinuria testing, statin prescription and flu and pneumococcal vaccination.

Results

Of 256 000 patients with biochemical CKD, 30% did not have a GP CKD code. Males, older patients, those with more severe CKD, diabetes or hypertension or those prescribed statins were more likely to have a CKD code. Among those with continued biochemical CKD following audit, these same characteristics increased the odds of improved coding. Patients without any kidney diagnosis were less likely to receive optimal care than those coded for CKD [e.g. odds ratio for meeting blood pressure target 0.78 (95% confidence interval 0.76–0.79)].

Conclusion

Older age, male sex, diabetes and hypertension are associated with coding for those with biochemical CKD. CKD coding is associated with receiving key primary care interventions recommended for CKD. Increased efforts to incentivize CKD coding may improve outcomes for CKD patients.

Prescribing quality in secondary care patients with different stages of chronic kidney disease: a retrospective study in the Netherlands

OBJECTIVES

Insight in the prescribing quality for patients with chronic kidney disease (CKD) in secondary care is limited. The aim of this study is to assess the prescribing quality in secondary care patients with CKD stages 3-5 and possible differences in quality between CKD stages.

DESIGN

This was a retrospective cohort study.

SETTING

Data were collected at two university (n=569 and n=845) and one non-university nephrology outpatient clinic (n=1718) in the Netherlands.

PARTICIPANTS

Between March 2015 and August 2016, data were collected from patients with stages 3a-5 CKD seen at the clinics. Blood pressure measurements, laboratory measurements and prescription data were extracted from medical records. For each prescribing quality indicator, patients with incomplete data required for calculation were excluded.

OUTCOME MEASURES

Potentially appropriate prescribing of antihypertensives, renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, phosphate binders and potentially inappropriate prescribing according to prevailing guidelines was assessed using prescribing quality indicators. Χ² or Fisher's exact tests were used to test for differences in prescribing quality.

RESULTS

RAAS inhibitors alone or in combination with diuretics (57% or 52%, respectively) and statins (42%) were prescribed less often than phosphate binders (72%) or antihypertensives (94%) when indicated. Active vitamin D was relatively often prescribed when potentially not indicated (19%). Patients with high CKD stages were less likely to receive RAAS inhibitors but more likely to receive statins when indicated than stage 3 CKD patients. They also received more active vitamin D and erythropoietin-stimulating agents when potentially not indicated.

CONCLUSIONS

Priority areas for improvement of prescribing in CKD outpatients include potential underprescribing of RAAS inhibitors and statins, and potential overprescribing of active vitamin D. CKD stage should be taken into account when assessing prescribing quality.

Risk factors of renal dysfunction and their interaction in level-low lead exposure paint workers

Background

To explore the effect of low-level lead exposure on renal dysfunction in paint works, and analyze the interaction between low-level lead exposure and other influence factors of renal dysfunction.

Methods

Seven hundred forty seven workers from Sany Heavy Industry Company and Xiangjiang Kansai Paint Company who have been exposed to paint were chosen by random cluster sampling. Their blood lead level and Urine β2-micro globulin level (renal dysfunction) were tested,risk factors of renal dysfunction in paint workers and their interactions were analyzed.

Results

The prevalence of renal dysfunction was 12.37%. Risk factors of renal dysfunction in paint workers mainly included longer working years (OR = 1.699, 95% CI: 1.226~ 2.355), blood lead positive (OR = 2.847, 95% CI: 1.577~ 5.139) and hypertension (OR = 2.192, 95% CI: 1.103~ 4.359). Positive interaction existed between hypertension and low-level blood lead on renal dysfunction in paint workers, the RERI (Relative excess risk of interaction), API (Attributable proportions of interaction) and S(the synergy index) were 4.758, 54.5% and 2.604 respectively.

Conclusions

Low-level lead exposure and hypertension not only have independent effect on renal dysfunction in paint workers, but also had obvious positive interaction in paint workers. Interventions aimed at blood lead and blood pressure at the same time will better prenvent from renal dysfunction.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5475-9) contains supplementary material, which is available to authorized users.

An ontological approach to identifying cases of chronic kidney disease from routine primary care data: a cross-sectional study

Background

Accurately identifying cases of chronic kidney disease (CKD) from primary care data facilitates the management of patients, and is vital for surveillance and research purposes. Ontologies provide a systematic and transparent basis for clinical case definition and can be used to identify clinical codes relevant to all aspects of CKD care and its diagnosis.

Methods

We used routinely collected primary care data from the Royal College of General Practitioners Research and Surveillance Centre. A domain ontology was created and presented in Ontology Web Language (OWL). The identification and staging of CKD was then carried out using two parallel approaches: (1) clinical coding consistent with a diagnosis of CKD; (2) laboratory-confirmed CKD, based on estimated glomerular filtration rate (eGFR) or the presence of proteinuria.

Results

The study cohort comprised of 1.2 million individuals aged 18 years and over. 78,153 (6.4%) of the population had CKD on the basis of an eGFR of < 60 mL/min/1.73m², and a further 7366 (0.6%) individuals were identified as having CKD due to proteinuria. 19,504 (1.6%) individuals without laboratory-confirmed CKD had a clinical code consistent with the diagnosis. In addition, a subset of codes allowed for 1348 (0.1%) individuals receiving renal replacement therapy to be identified.

Conclusions

Finding cases of CKD from primary care data using an ontological approach may have greater sensitivity than less comprehensive methods, particularly for identifying those receiving renal replacement therapy or with CKD stages 1 or 2. However, the possibility of inaccurate coding may limit the specificity of this method.

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.

Improving Care for Patients With or at Risk for Chronic Kidney Disease Using Electronic Medical Record Interventions: A Pragmatic Cluster-Randomized Trial Protocol

BACKGROUND

Many patients with or at risk for chronic kidney disease (CKD) in the primary care setting are not receiving recommended care.

OBJECTIVE

The objective of this study is to determine whether a multifaceted, low-cost intervention compared with usual care improves the care of patients with or at risk for CKD in the primary care setting.

DESIGN

A pragmatic cluster-randomized trial, with an embedded qualitative process evaluation, will be conducted.

SETTING

The study population comes from the Electronic Medical Record Administrative data Linked Database®, which includes clinical data for more than 140 000 rostered adults cared for by 194 family physicians in 34 clinics across Ontario, Canada. The 34 primary care clinics will be randomized to the intervention or control group.

INTERVENTION

The intervention group will receive resources from the "CKD toolkit" to help improve care including practice audit and feedback, printed educational materials for physicians and patients, electronic decision support and reminders, and implementation support.

MEASUREMENTS

Patients with or at risk for CKD within participating clinics will be identified using laboratory data in the electronic medical records. Outcomes will be assessed after dissemination of the CKD tools and after 2 rounds of feedback on performance on quality indicators have been sent to the physicians using information from the electronic medical records. The primary outcome is the proportion of patients aged 50 to 80 years with nondialysis-dependent CKD who are on a statin. Secondary outcomes include process of care measures such as screening tests, CKD recognition, monitoring tests, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker prescriptions, blood pressure targets met, and nephrologist referral. Hierarchical analytic modeling will be performed to account for clustering. Semistructured interviews will be conducted with a random purposeful sample of physicians in the intervention group to understand why the intervention achieved the observed effects.

CONCLUSIONS

If our intervention improves care, then the CKD toolkit can be adapted and scaled for use in other primary care clinics which use electronic medical records.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02274298.

Process quality indicators for chronic kidney disease risk management: a systematic literature review

BACKGROUND AND OBJECTIVES

Quality indicators (QIs) can be used for measuring the quality of actions of healthcare providers. This systematic review gives an overview of such QIs measuring processes of care for chronic kidney disease (CKD), and identifies the QIs that have content, face, operational and/or predictive validity.

METHODS

PubMed and Embase were searched using a strategy combining the terms "quality of care," "quality indicators" and "chronic kidney disease". Papers were included if they focused on developing, testing or applying QIs for assessing the quality of care in adult patients with CKD not on renal replacement therapy.

RESULTS

Two hundred and seventy-three QIs from thirty-one papers were extracted, including QIs on adequate monitoring of kidney function and vascular risk factors, on indicated treatment, drug safety, adherence and referral to a specialist. The QIs that were considered content, face and operational valid focused on monitoring of glomerular filtration rate, albumin-creatinine ratio, lipid levels and blood pressure, the use of non-steroidal anti-inflammatory drugs, nitrofurantoin and biphosphonates in patients with CKD, and QIs on monitoring haemoglobin and treatment with angiotensin-converting-enzyme-inhibitors/angiotensin-receptor-II-blockers in patients with CKD and comorbidities. No QIs were tested for predictive validity. In addition, only two QIs focused on diet and no other QIs focused on lifestyle management.

CONCLUSIONS

Based on this review, sufficiently validated QIs can be selected for measuring the quality of CKD care. This review provides insight in QIs that need further validation, and in areas of care where QIs are still lacking.

Key to Opening Kidney for In Vitro-In Vivo Extrapolation Entrance in Health and Disease: Part II: Mechanistic Models and In Vitro-In Vivo Extrapolation

It is envisaged that application of mechanistic models will improve prediction of changes in renal disposition due to drug-drug interactions, genetic polymorphism in enzymes and transporters and/or renal impairment. However, developing and validating mechanistic kidney models is challenging due to the number of processes that may occur (filtration, secretion, reabsorption and metabolism) in this complex organ. Prediction of human renal drug disposition from preclinical species may be hampered by species differences in the expression and activity of drug metabolising enzymes and transporters. A proposed solution is bottom-up prediction of pharmacokinetic parameters based on in vitro-in vivo extrapolation (IVIVE), mediated by recent advances in in vitro experimental techniques and application of relevant scaling factors. This review is a follow-up to the Part I of the report from the 2015 AAPS Annual Meeting and Exhibition (Orlando, FL; 25th-29th October 2015) which focuses on IVIVE and mechanistic prediction of renal drug disposition. It describes the various mechanistic kidney models that may be used to investigate renal drug disposition. Particular attention is given to efforts that have attempted to incorporate elements of IVIVE. In addition, the use of mechanistic models in prediction of renal drug-drug interactions and potential for application in determining suitable adjustment of dose in kidney disease are discussed. The need for suitable clinical pharmacokinetics data for the purposes of delineating mechanistic aspects of kidney models in various scenarios is highlighted.

An external validation of models to predict the onset of chronic kidney disease using population-based electronic health records from Salford, UK

BACKGROUND

Chronic kidney disease (CKD) is a major and increasing constituent of disease burdens worldwide. Early identification of patients at increased risk of developing CKD can guide interventions to slow disease progression, initiate timely referral to appropriate kidney care services, and support targeting of care resources. Risk prediction models can extend laboratory-based CKD screening to earlier stages of disease; however, to date, only a few of them have been externally validated or directly compared outside development populations. Our objective was to validate published CKD prediction models applicable in primary care.

METHODS

We synthesised two recent systematic reviews of CKD risk prediction models and externally validated selected models for a 5-year horizon of disease onset. We used linked, anonymised, structured (coded) primary and secondary care data from patients resident in Salford (population ~234 k), UK. All adult patients with at least one record in 2009 were followed-up until the end of 2014, death, or CKD onset (n = 178,399). CKD onset was defined as repeated impaired eGFR measures over a period of at least 3 months, or physician diagnosis of CKD Stage 3-5. For each model, we assessed discrimination, calibration, and decision curve analysis.

RESULTS

Seven relevant CKD risk prediction models were identified. Five models also had an associated simplified scoring system. All models discriminated well between patients developing CKD or not, with c-statistics around 0.90. Most of the models were poorly calibrated to our population, substantially over-predicting risk. The two models that did not require recalibration were also the ones that had the best performance in the decision curve analysis.

CONCLUSIONS

Included CKD prediction models showed good discriminative ability but over-predicted the actual 5-year CKD risk in English primary care patients. QKidney, the only UK-developed model, outperformed the others. Clinical prediction models should be (re)calibrated for their intended uses.

Results and lessons from the Spironolactone To Prevent Cardiovascular Events in Early Stage Chronic Kidney Disease (STOP-CKD) randomised controlled trial

OBJECTIVES

To determine whether low-dose spironolactone can safely lower arterial stiffness in patients with chronic kidney disease stage 3 in the primary care setting.

DESIGN

A multicentre, prospective, randomised, placebo-controlled, double-blinded study.

SETTING

11 primary care centres in South Birmingham, England.

PARTICIPANTS

Adult patients with stage 3 chronic kidney disease. Main exclusion criteria were diagnosis of diabetes mellitus, chronic heart failure, atrial fibrillation, severe hypertension, systolic blood pressure < 120 mm Hg or baseline serum potassium ≥ 5 mmol/L.

INTERVENTION

Eligible participants were randomised to receive either spironolactone 25 mg once daily, or matching placebo for an intended period of 40 weeks.

OUTCOME MEASURES

The primary end point was the change in arterial stiffness as measured by pulse wave velocity. Secondary outcome measures included the rate of hyperkalaemia, deterioration of renal function, barriers to participation and expected recruitment rates to a potential future hard end point study.

RESULTS

From the 11 practices serving a population of 112,462, there were 1598 (1.4%) patients identified as being eligible and were invited to participate. Of these, 134 (8.4%) attended the screening visit of which only 16 (1.0%) were eligible for randomisation. The main reasons for exclusion were low systolic blood pressure (<120 mm Hg: 40 patients) and high estimated glomerular filtration rate (≥ 60 mL/min/1.73 m(2): 38 patients). The trial was considered unfeasible and was terminated early.

CONCLUSIONS

We highlight some of the challenges in undertaking research in primary care including patient participation in trials. This study not only challenged our preconceptions, but also provided important learning for future research in this large and important group of patients.

TRIAL REGISTRATION NUMBER

ISRCTN80658312.

Chronic kidney disease prediction is an inexact science: The concept of “progressors” and “nonprogressors”

In 2002, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) instituted new guidelines that established a novel chronic kidney disease (CKD) staging paradigm. This set of guidelines, since updated, is now very widely accepted around the world. Nevertheless, the authoritative United States Preventative Task Force had in August 2012 acknowledged that we know surprisingly little about whether screening adults with no signs or symptoms of CKD improve health outcomes and that we deserve better information on CKD. More recently, the American Society of Nephrology and the American College of Physicians, two very well respected United States professional physician organizations were strongly at odds coming out with exactly opposite recommendations regarding the need or otherwise for ”CKD screening” among the asymptomatic population. In this review, we revisit the various angles and perspectives of these conflicting arguments, raise unanswered questions regarding the validity and veracity of the NKF KDOQI CKD staging model, and raise even more questions about the soundness of its evidence-base. We show clinical evidence, from a Mayo Clinic Health System Renal Unit in Northwestern Wisconsin, United States, of the pitfalls of the current CKD staging model, show the inexactitude and unpredictable vagaries of current CKD prediction models and call for a more cautious and guarded application of CKD staging paradigms in clinical practice. The impacts of acute kidney injury on CKD initiation and CKD propagation and progression, the effects of such phenomenon as the syndrome of late onset renal failure from angiotensin blockade and the syndrome of rapid onset end stage renal disease on CKD initiation, CKD propagation and CKD progression to end stage renal disease all demand further study and analysis. Yet more research on CKD staging, CKD prognostication and CKD predictions is warranted. Finally and most importantly, cognizant of the very serious limitations and drawbacks of the NKF K/DOQI CKD staging model, the need to individualize CKD care, both in terms of patient care and prognostication, cannot be overemphasized.