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American Journal of Kidney Diseases

Risk of CKD Progression and Quality-of-Care Indicators in the Primary Care Setting

  • Janet Yuen
    Affiliations
    Family Medicine, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Oksana Harasemiw
    Affiliations
    Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada

    Departments of Internal Medicine, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Alexander Singer
    Affiliations
    Family Medicine, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Aminu Bello
    Affiliations
    Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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  • Paul E. Ronksley
    Affiliations
    Departments of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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  • Clara Bohm
    Affiliations
    Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada

    Departments of Internal Medicine, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada

    Community Health Sciences, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Neil Drummond
    Affiliations
    Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada

    Departments of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada

    Family Medicine, University of Calgary, Calgary, Alberta, Canada
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  • Navdeep Tangri
    Correspondence
    Address for Correspondence: Navdeep Tangri, MD, PhD, Seven Oaks General Hospital, 2LB19-2300 McPhillips St, Winnipeg, MB R2V 3M3, Canada
    Affiliations
    Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada

    Departments of Internal Medicine, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada

    Community Health Sciences, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Published:September 01, 2022DOI:https://doi.org/10.1053/j.ajkd.2022.07.009
      To the Editor:
      Chronic kidney disease (CKD) progression follows a heterogeneous course, with a minority of individuals reaching kidney failure.
      • Abeysekera R.
      • Healy H.
      • Wang Z.
      • Cameron A.
      • Hoy W.
      Heterogeneity in patterns of progression of chronic kidney disease.
      When recognized early, progression in high-risk individuals can be reduced by managing upstream risk factors using disease-modifying medications, managing blood pressure (BP), and achieving adequate glycemic control.
      Kidney Disease Improving Global Outcomes
      Controversies Conference on Early Identification & Intervention in CKD. Mexico City; 2019.
      If treatment is delayed until nephrology referral, the therapeutic window for several disease-modifying drugs is narrowed or closed, and kidney failure can only be delayed, not prevented.
      Kidney Disease Improving Global Outcomes
      Controversies Conference on Early Identification & Intervention in CKD. Mexico City; 2019.
      Although most patients with CKD are managed in the primary care setting, for which treatment guidelines to mitigate risk currently exist,
      • Levin A.
      • Hemmelgarn B.
      • Culleton B.
      • et al.
      Guidelines for the management of chronic kidney disease.
      primary care providers may not be aware of current CKD treatment guidelines and thus quality-of-care indicators may not be met.
      • Bello A.K.
      • Ronksley P.E.
      • Tangri N.
      • et al.
      Quality of chronic kidney disease management in Canadian primary care.
      As such, implementing clinical tools in the primary care setting to improve early identification and stratification based on risk of progression to kidney failure is essential. The Kidney Failure Risk Equation (KFRE), which uses routinely collected variables to predict 2- and 5-year risks of kidney failure,
      • Tangri N.
      • Stevens L.A.
      • Griffith J.
      • et al.
      A predictive model for progression of chronic kidney disease to kidney failure.
      is one such tool. The KFRE has been validated in multiple populations
      • Tangri N.
      • Grams M.E.
      • Levey A.S.
      • et al.
      Multinational assessment of accuracy of equations for predicting risk of kidney failure ameta-analysis.
      ,
      • Major R.
      • Shepherd D.
      • Medcalf J.F.
      • Xu G.
      • Gray L.J.
      • Brunskill N.J.
      The Kidney Failure Risk Equation for prediction of end stage renal disease in UK primary care: an external validation and clinical impact projection cohort study.
      and is used to determine the intensity of care and timing of referral from primary care to nephrology in several jurisdictions worldwide.
      • Grill A.K.
      • Brimble S.
      Approach to the detection and management of chronic kidney disease.
      ,
      • Hingwala J.
      • Wojciechowski P.
      • Hiebert B.
      • et al.
      Risk-based triage for nephrology referrals using the Kidney Failure Risk Equation.
      It was also recently integrated into the National Institute for Health and Care Excellence CKD guidelines.
      We conducted a retrospective cohort study using data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) to evaluate CKD quality-of-care indictors. A cohort was developed of individuals managed in primary care clinics from January 1, 2010, through to December 31, 2019, who had at least 1 serum creatinine test with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 plus a urinary albumin-creatinine ratio (UACR), protein-creatinine ratio, or dipstick test available within ±365 days. Quality-of-care outcomes were compared between groups using the χ2 test. P < 0.05 was considered statistically significant. Detailed methods are presented in Item S1.
      We identified 24,143 individuals with CKD, 11,035 (45.7%) of whom had a UACR available and were included in the final analyses (Fig S1). Eighty-three percent of these individuals were at low risk of progressing to kidney failure, 10.3% were at intermediate risk, and 6.7% were at high risk (Table 1). Among intermediate- and high-risk individuals, 56% were on an ACEI/ARB and 38% on a statin, 65% of individuals with a recent BP measurement were within target, and only 30% received a nephrology referral (Fig 1). Table S1 displays results from a subgroup analysis of individuals with CKD GFR category 3 (G3)—a population in which all disease-modifying medications can be used, and where care is mostly led by primary care providers. Notably, in this group, SGLT2 inhibitor use was 12% or less in each risk group. Additionally, a sensitivity analysis performed in individuals with at least 2 eGFR tests <60 mL/min/1.73 m2 more than 90 days apart showed similar results to the main analyses (Table S2).
      Table 1Demographic and Clinical Data for Individuals With CKD categories G3-G5, Stratified by 5-Year Risk of Kidney Failure (N = 11,035)
      Low RiskIntermediate RiskHigh Risk
      No. of patients9,162 (83.0%)1,132 (10.3%)741 (6.7%)
      Age, y70.3 ± 12.573.4 ± 14.369.9 ± 15.5
      Age category
       18-44 y280 (3.1%)61 (5.4%)58 (7.8%)
       45-64 y2,473 (27.0%)200 (17.7%)166 (22.4%)
       65-84 y5,280 (57.6%)614 (54.2%)380 (51.3%)
       85+ y1,129 (12.3%)257 (23.7%)137 (18.5%)
      Female sex5,341 (58.3%)537 (47.4%)318 (42.9%)
      Province
       Alberta7,781 (84.9%)947 (83.7%)604 (81.5%)
       Manitoba1,381 (15.1%)185 (16.3%)137 (18.5%)
      Dwelling location
       Urban6,433 (71.9%)813 (74.9%)552 (76.8%)
       Rural2,510 (28.1%)273 (25.1%)167 (23.2%)
      Systolic BP, mm Hg
      Within±1 year of the index date.
      130.4 ± 18.0131.9 ± 20.3135.3 ± 24.0
      Diastolic BP, mm Hg
      Within±1 year of the index date.
      75.3 ± 10.972.5 ± 12.173.5 ± 13.0
      Body mass index, kg/m2
      Within±1 year of the index date.
      29.4 [25.9-33.9]29.3 [25.8-34.0]29.2 [25.4-34.3]
      Serum hemoglobin, g/dL
      Within±1 year of the index date.
      13.8 ± 1.712.8 ± 2.011.6 ± 2.2
      eGFR, mL/min/1.73 m254.3 [49.0-58.0]35.0 [29.7-42.0]20.6 [14.0-27.8]
      UACR, mg/mmol1.3 [0.8-2.9]9.1 [2.9-36.0]65.7 [15.0-196.0]
      HbA1c, among patients with known DM
      Within±1 year of the index date.
      6.9 [6.2-7.7]7.1 [6.4-8.2]7.3 [6.3-8.4]
      Comorbidities
      The presence/absence of comorbidities prior to the index date was assessed using validated definitions from the CPCSSN for each comorbidity.
       DM3,738 (40.8%)671 (59.3%)483 (65.2%)
       Dyslipidemia6,312 (68.9%)760 (67.1%)500 (67.5%)
       Hypertension5,815 (63.5%)841 (74.3%)570 (76.9%)
      Continuous variables given as mean ± SD or median [IQR]. eGFR calculated using the 2009 CKD-EPI creatinine equation without the race coefficient. Low risk defined as a 5-year risk of kidney failure <1%; intermediate risk as 1%-<5%; high risk as ≥5%. Abbreviations: DM, diabetes mellitus; HbA1c, glycated hemoglobin.
      a Within ±1 year of the index date.
      b The presence/absence of comorbidities prior to the index date was assessed using validated definitions from the CPCSSN for each comorbidity.
      Figure thumbnail gr1
      Figure 1Quality of care indicators for CKD, BP, and glycemic control stratified by 5-year kidney failure risk for individuals with CKD categories G3-G5 (N = 11,035). Prescriptions of disease-modifying medications, monitoring for glycemic control (HbA1c), and BP management were assessed within ±1 year of the index date; nephrology referrals were assessed at any time point. Count of antihyperglycemic medications does not include prescriptions of sodium-glucose cotransporter 2 inhibitors. Proportion of patients achieving a BP target of ≤140/90 mm Hg was assessed only among those with a BP measurement within ±1 year of the index date. Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; NSAIDs, nonsteroidal anti-inflammatory drugs; pt, patient.
      Kidney disease progression is associated with a high economic and quality-of-life burden and is an important issue for all health systems. Although there is reasonable access to primary care in Canada, the nephrology workforce is proportionately small and shrinking in Canada and the United States.
      • Levin A.
      Building blocks toward sustainable kidney care around the world: results from a multinational survey by the International Society of Nephrology.
      As such, most patients with CKD must be managed in primary care. When CKD is detected early (CKD categories G1-G3), a patient at high risk of kidney failure can potentially avoid kidney failure over their lifetime by using the available disease-modifying therapies, which can change the eGFR slope when eGFR is still preserved.
      Kidney Disease Improving Global Outcomes
      Controversies Conference on Early Identification & Intervention in CKD. Mexico City; 2019.
      Conversely, if interventions are instituted in CKD category G4, fewer disease-modifying therapies are available and kidney failure can only be delayed.
      Kidney Disease Improving Global Outcomes
      Controversies Conference on Early Identification & Intervention in CKD. Mexico City; 2019.
      Our findings suggest that although intermediate- and high-risk patients receive more disease-modifying therapies compared to low-risk patients, the gap between the quality-of-care indicators met in intermediate- and high-risk patients is minimal. These findings suggest the need for active dissemination and implementation of the most recent nephrology guidelines in primary care, and integration of tools such as the KFRE into clinical workflow to identify and risk-stratify patients with CKD earlier and aid in appropriate management to either delay or prevent kidney failure. Imperatively, we advocate for increased albuminuria testing to improve CKD identification and management, as well as to facilitate the use of the KFRE.
      Using known quality indicators, we identified several areas for improvement in the care of individuals with CKD categories G3-G5 in primary care settings. Addressing these gaps could lead to clinically meaningful delays in progression to kidney failure for patients who are at intermediate and high risk of this outcome. Future studies examining the impact of implementing risk-based care approaches and tools that improve clinical workflow to optimize care in the CKD population are needed.

      Article Information

      Authors’ Contributions

      Concept and design: NT, OH; acquisition, analysis, or interpretation of data: all authors; statistical analysis: OH; administrative, technical, or material support: OH; supervision: NT. Each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual’s own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work, even one in which the author was not directly involved, are appropriately investigated and resolved, including with documentation in the literature if appropriate.

      Support

      This work was funded by the Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) Network, which is supported by the Canadian Institutes of Health Research (CIHR) under Canada’s Strategy for Patient Oriented Research grant 20R26070. The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

      Financial Disclosure

      NT developed and validated the KFRE and is engaged in several federally funded and industry-supported grants to implement the KFRE in electronic health records and laboratory information systems. NT is also the founder of ClinPredict Inc and Klinrisk Inc; both entities develop and implement prediction models for clinical outcomes in patients with CKD in electronic health records. The other authors declare that they have no relevant financial interests.

      Peer Review

      Received February 16, 2022. Evaluated by 2 external peer reviewers, with direct editorial input from a Statistics/Methods Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form July 17, 2022.

      Supplementary Material

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