Evaluation and Treatment of CKD Patients Before and at Their First Nephrologist Encounter in Canada
Received 4 March 2007; accepted 7 August 2007. published online 01 October 2007.
Background
Much of the comorbidity associated with chronic kidney disease (CKD) begins in the early stages. Interventions with proven efficacy exist to decrease progression, morbidity, and mortality. This study examines their use in patients with CKD before and at their first nephrologist encounter in Canada.
Study Design
Prospective multicenter cohort study.
Setting & Participants
482 patients at their first nephrologist encounter enrolled from 13 Canadian centers. Inclusion criteria were measured or estimated glomerular filtration rate less than 50 mL/min/1.73 m2. Exclusion criteria were patients with acute kidney failure or those likely to require dialysis therapy within 3 months of referral.
Outcomes & Measurements
Describe: (1) characteristics of patients at their first nephrology encounter in Canada; (2) the evaluation for cardiac risk factors, cardiac diseases and CKD complications and their management before the encounter; (3) changes in management initiated by nephrologists at the first encounter; and (4) the availability and use of allied health professional services for CKD care.
Results
Patients had a mean age of 69.7 years, estimated glomerular filtration rate of 29 mL/min/1.73 m2 (0.48 mL/s/1.73 m2, hemoglobin level of 12.1 g/dL (121 g/L), albumin level of 3.6 g/dL (36 g/L), and blood pressure of 147/76 mm Hg. Transmission of results from prior evaluation was variable. At the encounter, nephrologists had available or ordered albumin and calcium/phosphate tests in greater than 70% of patients. Nephrologists did not evaluate parathyroid hormone in 83% of patients, lipids in greater than 50%, iron studies (in those with anemia) in 57%, and urine studies in 30%. Despite a high prevalence of diabetes and coronary artery disease, only 46% were administered medications to interrupt the renin-angiotensin system, 37% were administered acetylsalicylic acid, and 32% were administered lipid medication after the encounter. Availability and use of allied health professional resources varied and was low in an unstructured setting.
Limitations
External validity, referral bias, and inability to make causal inferences.
Conclusions
In Canada, patients with CKD continue to be encountered late by nephrologists (stage IV CKD). Information for prior evaluation is incompletely transmitted. Finally, there appears to be room for improvement in evaluation and treatment at the first nephrologist encounter.
1Division of Nephrology and Clinical Epidemiology, Memorial University of Newfoundland, St John’s, Newfoundland, Canada
2Centre for Health Evaluation and Outcome Sciences (CHEOS), St Paul’s Hospital, Vancouver, Canada
3St Paul’s Hospital, University of British Columbia, Vancouver, Canada
4Division of Nephrology, St Paul’s Hospital, University of British Columbia, Vancouver, Canada.
Address correspondence to Bryan M. Curtis, MD, Assistant Professor of Medicine, Nephrology & Clinical Epidemiology, Memorial University of Newfoundland, Patient Research Centre, Health Sciences Centre, 300 Prince Philip Dr, St John’s, NFLD, Canada A1B 3V6.
ABSTRACT