Management of Advanced Chronic Kidney Disease in Primary Care
Management of Advanced Chronic Kidney Disease in Primary Care
The quality of chronic kidney disease (CKD) care and the control of CKD progression factors and of comorbid conditions according to current recommendations in primary care were investigated in this retrospective cohort study of 127 consecutive CKD patients. CKD was advanced (glomerular filtration rate 21 ± 10 ml/min). Fifty-seven per cent of patients had been evaluated to clarify CKD aetiology. Blood pressure was substantially elevated (148 ± 20/83 ± 11 mmHg) and only 39% of patients achieved target blood pressure levels. At a mean HbA1c of 6.5 ± 1.1%, glycaemic control was good in 63% of diabetics. Mean haemoglobin was 10.8 ± 1.8 g/dl, and anaemia was adequately controlled in 49%. In 42% the management of bone disease and in 80% the nutritional status was sufficient. Angiotensin converting enzyme inhibitors or angiotensin-2-receptor blockers was used in 59% of patients with diabetic nephropathy or proteinuria above 1 g/day. High-total quality of care was only achieved in 35% which suggests that the management of advanced CKD in primary care is suboptimal.
The growing incidence and prevalence of chronic kidney disease (CKD) are a worldwide public health problem. CKD has been identified as a major cause of morbidity and mortality, especially due to associated comorbid conditions and cardiovascular disease (CVD). In CKD, common causes and comorbid conditions are strong cardiovascular risk factors. Consequently, cardiovascular morbidity and mortality are exceptionally high in CKD, especially in advanced stages of CKD. Moreover, these comorbid conditions and cardiovascular risk factors have already a negative impact at early stages of CKD. Furthermore, CKD may progress to end-stage renal failure, which aggravates comorbid conditions and CVD. There are effective interventions to reduce the morbidity and mortality associated with CKD: (i) to identify and treat potentially reversible causes of CKD; (ii) to delay or prevent CKD progression, and (iii) to ameliorate or correct comorbid conditions and cardiovascular risk factors. To be most effective, these interventions should be initiated as early as possible in the course of CKD. Nephrological co-management has been associated with a beneficial outcome in CKD patients who subsequently progressed to end-stage renal disease. Despite recommendations advocating early nephrological co-management, in most countries primary care physicians without specialized nephrological training carry the burden to manage the majority of CKD patients alone, even at advanced stages, and may continue to do so in the future. In contrast to the importance of effective CKD management, there is limited information about the quality of care of advanced CKD patients in primary care. This data is essential to identify strengths and deficits of CKD management in primary care and to develop concepts which may improve care accordingly. Purpose of this study was to assess the diagnostic management, the management of potentially modifiable CKD progression factors, of comorbid conditions, and of cardiovascular risk factors, and the total quality of care in advanced CKD patients in primary care before nephrological referral compared with current recommendations.
Summary and Introduction
Summary
The quality of chronic kidney disease (CKD) care and the control of CKD progression factors and of comorbid conditions according to current recommendations in primary care were investigated in this retrospective cohort study of 127 consecutive CKD patients. CKD was advanced (glomerular filtration rate 21 ± 10 ml/min). Fifty-seven per cent of patients had been evaluated to clarify CKD aetiology. Blood pressure was substantially elevated (148 ± 20/83 ± 11 mmHg) and only 39% of patients achieved target blood pressure levels. At a mean HbA1c of 6.5 ± 1.1%, glycaemic control was good in 63% of diabetics. Mean haemoglobin was 10.8 ± 1.8 g/dl, and anaemia was adequately controlled in 49%. In 42% the management of bone disease and in 80% the nutritional status was sufficient. Angiotensin converting enzyme inhibitors or angiotensin-2-receptor blockers was used in 59% of patients with diabetic nephropathy or proteinuria above 1 g/day. High-total quality of care was only achieved in 35% which suggests that the management of advanced CKD in primary care is suboptimal.
Introduction
The growing incidence and prevalence of chronic kidney disease (CKD) are a worldwide public health problem. CKD has been identified as a major cause of morbidity and mortality, especially due to associated comorbid conditions and cardiovascular disease (CVD). In CKD, common causes and comorbid conditions are strong cardiovascular risk factors. Consequently, cardiovascular morbidity and mortality are exceptionally high in CKD, especially in advanced stages of CKD. Moreover, these comorbid conditions and cardiovascular risk factors have already a negative impact at early stages of CKD. Furthermore, CKD may progress to end-stage renal failure, which aggravates comorbid conditions and CVD. There are effective interventions to reduce the morbidity and mortality associated with CKD: (i) to identify and treat potentially reversible causes of CKD; (ii) to delay or prevent CKD progression, and (iii) to ameliorate or correct comorbid conditions and cardiovascular risk factors. To be most effective, these interventions should be initiated as early as possible in the course of CKD. Nephrological co-management has been associated with a beneficial outcome in CKD patients who subsequently progressed to end-stage renal disease. Despite recommendations advocating early nephrological co-management, in most countries primary care physicians without specialized nephrological training carry the burden to manage the majority of CKD patients alone, even at advanced stages, and may continue to do so in the future. In contrast to the importance of effective CKD management, there is limited information about the quality of care of advanced CKD patients in primary care. This data is essential to identify strengths and deficits of CKD management in primary care and to develop concepts which may improve care accordingly. Purpose of this study was to assess the diagnostic management, the management of potentially modifiable CKD progression factors, of comorbid conditions, and of cardiovascular risk factors, and the total quality of care in advanced CKD patients in primary care before nephrological referral compared with current recommendations.
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