This Month in AJKD
Article Outline
- Is There a Need to Enhance CKD Education for Physician Providers?
- Decline in Use of Peritoneal Dialysis
- Proteinuria as a Surrogate Outcome in CKD
- Update on Cardiovascular Disease Associated With CKD in Children
Is There a Need to Enhance CKD Education for Physician Providers?
See Charles et al, pages 227-237; Israni et al, pages 238-247; and Wasse and McClellan, pages 187-190.
Strengthening provider education is a central feature of efforts to facilitate the translation of evidence-based CKD care into community practice. Two articles in this issue of AJKD probe primary care physician knowledge of CKD using clinical vignettes and accompanying quizzes. In the first article by Charles et al, respondents from a national random sample of US physicians were evaluated on their utilization of stage-appropriate clinical testing in CKD, and the cost implications of both overtesting and undertesting. Overall, only 35% of participants ordered at least 5 of the 6 stage-appropriate clinical tests while 85% ordered additional tests that were not recommended in clinical guidelines, resulting in a 23% cost increase. In the second article, Israni et al focused solely on primary care physicians, and noted that those physicians who were younger and closer to the completion of training were more likely to recognize CKD and identify proper blood pressure targets and management strategies. An editorial by Wasse and McClellan suggests that these and similar survey data should be considered when developing the content and focus for the next iteration of CKD educational programs.
Decline in Use of Peritoneal Dialysis
See Mehrotra et al, pages 289-298; and Blake, pages 194-196.
Peritoneal dialysis (PD) utilization has declined in the United States, despite the potential for substantial taxpayer savings with similar healthcare outcomes. In this issue, Mehrotra et al analyze US Renal Data System data to evaluate the interaction between PD use and ownership patterns of dialysis units from 1996 to 2004. Over the 9-year period, 785,531 patients started maintenance dialysis and the proportion of patients receiving care in 5 large dialysis organizations (LDOs) increased from 39% to 63%. They report that LDO-affiliated units generally use PD less than non-LDO units although there was significant variability among the LDOs, and facilities with lower PD utilization had higher patient mortality and technique failure rates compared to those units with greater PD utilization. An editorial by Dr Blake explores potential factors underlying the decline in PD use both nationally and internationally.
Proteinuria as a Surrogate Outcome in CKD
See Levey et al, pages 205-226.
Changes in proteinuria have been suggested as a surrogate outcome for kidney disease progression to facilitate conduct of clinical trials. In this issue, Levey et al summarize a workshop sponsored by the National Kidney Foundation and the US Food and Drug Administration with the following goals: (1) to evaluate the strengths and limitations of criteria for assessment of proteinuria as a potential surrogate endpoint for clinical trials in CKD, (2) to explore the strengths and limitations of available data on proteinuria as a potential surrogate endpoint, and (3) to delineate what more needs to be done to evaluate proteinuria as a potential surrogate endpoint. The authors first review the importance of proteinuria in CKD and discuss surrogate endpoints in clinical trials of drug therapy, then summarize data on proteinuria as a potential surrogate outcome in 3 broad clinical areas: early diabetic kidney disease, nephrotic syndrome, and diseases with mild-to-moderate proteinuria. They conclude that there appears to be sufficient evidence to recommend changes in proteinuria as a surrogate for kidney disease progression only in selected circumstances at the present time. Further research is needed to define additional contexts in which changes in proteinuria can be expected to predict treatment effect.
Update on Cardiovascular Disease Associated With CKD in Children
See Wilson and Mitsnefes, pages 345-360.
In young adult survivors of childhood-onset CKD, cardiovascular disease is the most common cause of death. The likely reason for increased cardiovascular disease in these patients is high prevalence of both traditional and uremia-related cardiovascular disease risk factors. Early markers of cardiomyopathy, such as left ventricular hypertrophy and left ventricular dysfunction and early markers of atherosclerosis, such as increased carotid artery intima-media thickness, carotid arterial wall stiffness, and coronary artery calcification are frequently found in this patient population. In this issue, Wilson and Mitsnefes provide an update of recent advances in the understanding and management of cardiovascular disease risks in this population. After a review of the literature, they conclude that cardiovascular risk factors and early cardiovascular changes are common even in very young patients, and much remains to be done to define and achieve optimal management of these patients.
Image courtesy of 3M.
PII: S0272-6386(09)00891-9
doi:10.1053/S0272-6386(09)00891-9
Refers to article:
- Clinical Testing Patterns and Cost Implications of Variation in the Evaluation of CKD Among US Physicians , 16 April 2009
- Physician Characteristics and Knowledge of CKD Management , 10 April 2009
- Increasing Physician Knowledge About the Diagnosis and Management of CKD: How Can We Help Primary Care Providers?
- Ownership Patterns of Dialysis Units and Peritoneal Dialysis in the United States: Utilization and Outcomes , 09 April 2009
- Proliferation of Hemodialysis Units and Declining Peritoneal Dialysis Use: An International Trend
- Proteinuria as a Surrogate Outcome in CKD: Report of a Scientific Workshop Sponsored by the National Kidney Foundation and the US Food and Drug Administration , 06 July 2009
- Cardiovascular Disease in CKD in Children: Update on Risk Factors, Risk Assessment, and Management
