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Mutatiri C, Ratsch A, McGrail M, Venuthurupalli SK, Chennakesavan SK. Primary and specialist care interaction and referral patterns for individuals with chronic kidney disease: a narrative review. BMC Nephrol 2024; 25:149. [PMID: 38689219 PMCID: PMC11061991 DOI: 10.1186/s12882-024-03585-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease. OBJECTIVE The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process. METHODS A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023. RESULTS Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early. CONCLUSIONS This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services.
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Affiliation(s)
- Clyson Mutatiri
- Renal Medicine, Wide Bay Hospital and Health Service, Bundaberg, QLD, Australia.
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Bundaberg, QLD, Australia.
| | - Angela Ratsch
- Research Services, Wide Bay Hospital and Health Service, Hervey Bay, QLD, Australia
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Hervey Bay, QLD, Australia
| | - Matthew McGrail
- Rural Clinical School, Faculty of Medicine, The University of Queensland, Rockhampton, QLD, Australia
| | - Sree Krishna Venuthurupalli
- Kidney Service, Department of Medicine, West Moreton Hospital and Health Service, Ipswich, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Mattocks KM, Kroll-Desrosiers A, Crowley S, Tuozzo K, Rifkin I, Moore D, Walker L, Bonegio R. Using RE-AIM to examine implementation of a tele-nephrology program for veterans living in rural areas. FRONTIERS IN HEALTH SERVICES 2023; 3:1205951. [PMID: 37780402 PMCID: PMC10533984 DOI: 10.3389/frhs.2023.1205951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023]
Abstract
Introduction Chronic kidney disease (CKD) and refractory hypertension (rHTN) are common, chronic conditions that affect 10%-16% of Veterans. Several small studies have suggested that tele-nephrology can deliver nephrology care effectively to rural Veterans. The purpose of this evaluation was to examine perceptions and experiences with this tele-nephrology program among spoke site staff and clinicians using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to guide our understanding of tele-nephrology implementation. Methods We conducted semi-structured interviews with fourteen clinicians at five tele-nephrology spoke sites. We used content analysis to analyze the results using our RE-AIM framework. Results Five major themes arose: (1) Active engagement of a centralized clinical champion was a key factor in early success of tele-nephrology program; (2) Transition from community-based nephrology to VA tele-nephrology was heralded as the most meaningful indicator of the effectiveness of the intervention; (3) Effective adoption strategies included bi-weekly training with Hub nephrology staff and engagement of a local renal champion; (4) Meeting the needs of Veterans through proper staffing during tele-nephrology examinations was a key priority in facility program implementation; and (5) Growing reliance on Hub nephrologists may give rise to insufficient availability of nephrology appointments in some Spoke sites. Discussion This evaluation represents an important step forward as VA considers how to provide care to Veterans at facilities without VA specialty providers. The COVID-19 pandemic has drastically shifted options for Veterans, and increasingly, the VA is moving to shift care from community to VA via virtual care. Further research should examine how the VA manages potential problems related to access to virtual providers and examine Veteran perspectives on community in-person vs. virtual VA care.
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Affiliation(s)
- Kristin M. Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA, United States
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Aimee Kroll-Desrosiers
- VA Central Western Massachusetts Healthcare System, Leeds, MA, United States
- Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Susan Crowley
- VA Connecticut Healthcare System, West Haven, CT, United States
- Yale University School of Medicine, New Haven, CT, United States
| | | | - Ian Rifkin
- VA Boston Healthcare System, Boston, MA, United States
- Boston University School of Medicine, Boston, MA, United States
| | - David Moore
- VA Connecticut Healthcare System, West Haven, CT, United States
- Yale University School of Medicine, New Haven, CT, United States
| | - Lorrie Walker
- VA Central Western Massachusetts Healthcare System, Leeds, MA, United States
| | - Ramon Bonegio
- VA Boston Healthcare System, Boston, MA, United States
- Boston University School of Medicine, Boston, MA, United States
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Williams P. Retaining Race in Chronic Kidney Disease Diagnosis and Treatment. Cureus 2023; 15:e45054. [PMID: 37701164 PMCID: PMC10495104 DOI: 10.7759/cureus.45054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/14/2023] Open
Abstract
The best overall measure of kidney function is glomerular filtration rate (GFR) as commonly estimated from serum creatinine concentrations (eGFRcr) using formulas that correct for the higher average creatinine concentrations in Blacks. After two decades of use, these formulas have come under scrutiny for estimating GFR differently in Blacks and non-Blacks. Discussions of whether to include race (Black vs. non-Black) in the calculation of eGFRcr fail to acknowledge that the original race-based eGFRcr provided the same CKD treatment recommendations for Blacks and non-Blacks based on directly (exogenously) measured GFR. Nevertheless, the National Kidney Foundation and the American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease removed race in CKD treatment guidelines and pushed for the immediate adoption of a race-free eGFRcr formula by physicians and clinical laboratories. This formula is projected to negate CKD in 5.51 million White and other non-Black adults and reclassify CKD to less severe stages in another 4.59 million non-Blacks, in order to expand treatment eligibility to 434,000 Blacks not previously diagnosed and to 584,000 Blacks previously diagnosed with less severe CKD. This review examines: 1) the validity of the arguments for removing the original race correction, and 2) the performance of the proposed replacement formula. Excluding race in the derivation of eGFRcr changed the statistical bias from +3.7 to -3.6 ml/min/1.73m2 in Blacks and from +0.5 to +3.9 in non-Blacks, i.e., promoting CKD diagnosis in Blacks at the cost of restricting diagnosis in non-Blacks. By doing so, the revised eGFRcr greatly exaggerates the purported racial disparity in CKD burden. Claims that the revised formulas identify heretofore undiagnosed CKD in Blacks are not supported when studies that used kidney failure replacement therapy and mortality are interpreted as proxies for baseline CKD. Alternatively, a race-stratified eGFRcr (i.e., separate equations for Blacks and non-Blacks) would provide the least biased eGFRcr for both Blacks and non-Blacks and the best medical treatment for all patients.
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Affiliation(s)
- Paul Williams
- Life Sciences, Lawrence Berkeley National Laboratory, Berkeley, USA
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Morales J, Dagogo-Jack S, Fonseca V, Neumiller JJ, Rosas SE. Perspectives on Chronic Kidney Disease With Type 2 Diabetes and Risk Management: Practical Viewpoints and a Paradigm Shift Using a Pillar Approach. Clin Diabetes 2023; 41:553-566. [PMID: 37849516 PMCID: PMC10577512 DOI: 10.2337/cd22-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Affiliation(s)
| | - Sam Dagogo-Jack
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, Memphis, TN
| | - Vivian Fonseca
- Department of Medicine and Pharmacology, School of Medicine, Tulane University, New Orleans, LA
| | - Joshua J. Neumiller
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Pullman, WA
| | - Sylvia E. Rosas
- Joslin Diabetes Center and Harvard Medical School, Boston, MA
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Kelepouris E, St Peter W, Neumiller JJ, Wright EE. Optimizing Multidisciplinary Care of Patients with Chronic Kidney Disease and Type 2 Diabetes Mellitus. Diabetes Ther 2023:10.1007/s13300-023-01416-2. [PMID: 37209236 DOI: 10.1007/s13300-023-01416-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/19/2023] [Indexed: 05/22/2023] Open
Abstract
Diabetes is the leading cause of chronic kidney disease (CKD), a condition associated with significant morbidity and mortality. As these patients have a high risk of developing cardiovascular disease and end-stage kidney disease, there is a need for early detection and early initiation of appropriate therapeutic interventions that slow disease progression and prevent adverse outcomes. Due to the complex nature of diabetes and CKD management, a holistic, patient-centered, collaborative care approach delivered by a coordinated multidisciplinary team (ideally including a clinical pharmacist as part of a comprehensive medication management program) is needed. In this review, we discuss the barriers to effective care, the current multidisciplinary approach used for CKD prevention and treatment, and the potential ways that the multidisciplinary management of CKD associated with type 2 diabetes mellitus can be refined to improve patient outcomes.
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Affiliation(s)
- Ellie Kelepouris
- Division of Renal Electrolyte and Hypertension, University of Pennsylvania, Philadelphia, PA, USA.
| | - Wendy St Peter
- University of Minnesota, Minneapolis, MN, USA
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
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Wright WL, Urquhart S, Brunton S. Beyond Blood Glucose and Blood Pressure Control in Type 2 Diabetes: Alternative Management Strategies to Prevent the Development and Progression of CKD. J Prim Care Community Health 2023; 14:21501319231153599. [PMID: 36935560 PMCID: PMC10031227 DOI: 10.1177/21501319231153599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023] Open
Abstract
Chronic kidney disease associated with Type 2 diabetes is linked to significant increase in morbidity, reduced quality of life, and early death. Current guidelines recommend targets for the management of hyperglycemia, hypertension, and dyslipidemia but there remains a residual risk of chronic kidney disease progression and adverse cardiovascular outcomes in patients with Type 2 diabetes. The 2022 consensus report from the American Diabetes Association and Kidney Disease: Improving Global Outcomes support the use of sodium-glucose co-transporter 2 inhibitors and nonsteroidal mineralocorticoid receptor antagonists to improve kidney and cardiovascular outcomes. Coordination between those working in the primary care setting and those in endocrinology and nephrology clinics may optimize the prevention of chronic kidney disease progression in patients with Type 2 diabetes. Nurse practitioners, physician assistants, and primary care physicians play an important role in making timely patient referrals to kidney specialists. This article explores the use of novel therapies capable of reducing the risk of cardiovascular disease and chronic kidney disease progression beyond what can be achieved with control of blood glucose, blood pressure, and lipid levels. It also discusses the importance of monitoring at-risk patients to facilitate early diagnosis and initiation of effective kidney-protective therapy.[Media: see text][Figure: see text].
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Affiliation(s)
- Wendy L Wright
- Wright and Associates Family Healthcare, Amherst and Concord, NH, USA
| | - Scott Urquhart
- Diabetes and Thyroid Associates, Fredericksburg, VA, USA
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Khatri N, Nasir K, Dhrolia M, Qureshi R, Ahmad A. Delay in Permanent Vascular Access Formation and Referral to a Nephrologist in Incident Hemodialysis Patients: A Single Center Experience. Cureus 2021; 13:e20728. [PMID: 35111422 PMCID: PMC8790666 DOI: 10.7759/cureus.20728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study assessed the factors associated with delayed referral to a nephrologist and delay in formation of a permanent vascular access in incident hemodialysis (HD) patients. METHODS This prospective cross-sectional study was conducted from February 2021 to July 2021 on end stage renal disease (ESRD) patients receiving maintenance hemodialysis (MHD) at our center. Data were collected at the bedside during the HD session about a referral to a nephrologist, about when they were asked for permanent vascular access formation and the reason for the delay in its formation. Results: Out of 296 patients recruited in our study, 168 (56.8%) were male and 128 (43.2) were female. The mean age was 53.5±15 years (minimum of 19 years and maximum of 90 years). The most common reason for refusal of making permanent vascular access [arterio-venous fistula (AVF) or arterio-venous graft (AVG)] was fear of pain in our patients 65 (43.3%) followed by the denial of the disease 32 (21.3%). Among the study subjects, 231 (78%) patients were referred to the nephrologist immediately or within one month of their diagnosis. Some 152 (51.4%) of the patients were not in favor of making AVF whereas 151 (51%) refused for starting HD, hence most of our patients 181 (61.1%) initiated HD in emergency by a central venous catheter (CVC). CONCLUSION Early referral should be done by primary care physicians (PCPs) for the timely management of CKD patients. As CKD is a progressive disease, it requires special attention by a nephrologist for adjustment of patient's medications, timely follow-up, counseling, the early formation of AVF for HD, and planning for renal transplant. In our study, the majority of our patients initiated their HD via CVC because of the delayed visit to a nephrologist. Most patients were asked for AVF formation on the same day of presentation to our nephrology unit as they had advanced CKD (Stage 5) 134 (51.4%). Most patients in our study delayed AVF formation 152 (51.4%). With timely referral to a nephrologist, the nephrologist will be able to do better and repeated counseling about the disease, its progression, and the need for permanent vascular access for initiation of HD while patients and their families will get more time to make decisions.
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Affiliation(s)
- Natasha Khatri
- Nephrology, The Kidney Centre Post Graduate Training Institute, Karachi, PAK
| | - Kiran Nasir
- Nephrology, The Kidney Centre Post Graduate Training Institute, Karachi, PAK
| | - Murtaza Dhrolia
- Nephrology, The Kidney Centre Post Graduate Training Institute, Karachi, PAK
| | - Ruqaya Qureshi
- Nephrology, The Kidney Centre Post Graduate Training Institute, Karachi, PAK
| | - Aasim Ahmad
- Nephrology, The Kidney Center Post Graduate Training Institute, Karachi, PAK
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