Detection and Awareness of Moderate to Advanced CKD by Primary Care Practitioners: A Cross-sectional Study From Italy
Received 5 September 2007; accepted 3 March 2008. published online 13 May 2008.
Background
Chronic kidney disease (CKD) is a strong independent predictor of cardiovascular disease. Although general practitioners (GPs) represent the first line for identification of these high-risk patients, their diagnostic approach to CKD is ill defined.
Study Design
Cross-sectional evaluation of database of Italian GPs.
Setting & Participants
Representative sample of adult Italian population regularly followed up by GPs in 2003.
Outcomes
Frequency of serum creatinine testing, prevalence of CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2), awareness of CKD assessed from use of diagnostic codes (Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) for CKD, and referral to nephrologists.
Results
Of 451,548 individuals in the entire practice population, only 77,630 (17.2%) underwent serum creatinine testing. Female sex (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.06 to 1.12), advanced age (OR, 2.70; 95% CI, 2.63 to 2.78), diabetes (OR, 1.31; 95% CI, 1.20 to 1.42), hypertension (OR, 1.10; 95% CI, 1.02 to 1.19), autoimmune diseases (OR, 1.42; 95% CI, 1.11 to 1.82), and recurrent urinary tract infections (OR, 1.63; 95% CI, 1.10 to 2.42) were all associated with serum creatinine testing. Conversely, use of either nonsteroidal anti-inflammatory drugs (OR, 1.03; 95% CI, 0.89 to 1.21) or aminoglycosides or contrast media (OR, 0.78; 95% CI, 0.54 to 1.14) was not associated with serum creatinine testing. In the subgroup with serum creatinine data, the age-adjusted prevalence of CKD was 9.33% (11.93% in women, 6.49% in men). However, in patients with eGFR less than 60 mL/min/1.73 m2, serum creatinine values were apparently normal (<1.2 mg/dL in women, <1.4 mg/dL in men) in 54%, and GPs used ICD-9-CM codes for CKD in only 15.2%. Referral to nephrologists ranged from 4.9% for patients with eGFR of 59 to 30 mL/min/1.73 m2 to 55.7% for those with eGFR less than 30 mL/min/1.73 m2.
Limitations
The prevalence of decreased kidney function may be overestimated because of the more frequent serum creatinine testing in sicker individuals and lack of creatinine calibration.
Conclusions
In primary care, CKD stages 3 to 5 are frequent, but its awareness is scarce because of limited rates of serum creatinine testing and difficulty recognizing decreased eGFR in the absence of increased serum creatinine testing.
ABSTRACT