Abstract
BackgroundIn developing countries, renal specialists are scarce and physician-to-patient contact time is limited. While conventional hospital-based, physician-oriented approach has been the main focus of chronic kidney disease (CKD) care, a comprehensive multidisciplinary health care program (Integrated CKD Care) has been introduced as an alternate intervention to delay CKD progression in a community population. The main objective is to assess effectiveness of Integrated CKD Care in delaying CKD progression.MethodsWe carried out a community-based, cluster randomized controlled trial. Four hundred forty-two stage 3-4 CKD patients were enrolled. In addition to the standard treatments provided to both groups, the patients in the intervention group also received “Integrated CKD Care”. This was delivered by a multidisciplinary team of hospital staff in conjunction with a community CKD care network (subdistrict healthcare officers and village health volunteers) to provide group counseling during each hospital visit and quarterly home visits to monitor compliance with the treatment. Duration of the study was 2 years. The primary outcome was difference of mean eGFR between the intervention and the control groups over the study period.ResultsThe mean difference of eGFR over time in the intervention group was significantly lower than the control group by 2.74 ml/min/1.73 m2 (95%CI 0.60–4.50, p = 0.009). Seventy composite clinical endpoints were reported during the study period with significantly different incidences between the control and the intervention groups (119.1 versus 69.4 per 1000 person-years; hazard ratio (HR) 0.59, 95% CI 0.4–0.9, p = 0.03).ConclusionIntegrated CKD Care can delay CKD progression in resource-limited settings.Trial registration(NCT01978951). Prospectively registered as of December 8, 2012.
Highlights
In developing countries, renal specialists are scarce and physician-to-patient contact time is limited
This study was aimed to compare the effectiveness on delaying chronic kidney disease (CKD) progression between a conventional and an integrated CKD care (ICC) provided by a multidisciplinary care team (MDCT) of hospital staffs in conjunction with the a community CKD care network (CCN, subdistrict health care officers and village health volunteers (VHVs))
Most of baseline clinical and laboratory characteristics, including estimated Glomerular Filtration Rate (eGFR), of the two groups were comparable; the levels of HbA1c, 24-h urine sodium and normalized Protein Nitrogen Appearance of the control group were slightly higher than intervention group (Table 1)
Summary
Renal specialists are scarce and physician-to-patient contact time is limited. While conventional hospital-based, physician-oriented approach has been the main focus of chronic kidney disease (CKD) care, a comprehensive multidisciplinary health care program (Integrated CKD Care) has been introduced as an alternate intervention to delay CKD progression in a community population. The total number of pre-dialysis CKD patients in Thailand has been estimated at 4.1 million, which is impossible for the currently available 450 nephrologists to deal with. This nephrologist-to-patient ratio of 1:15,000 indicated that traditional physicianbased approach is inadequate for ensuring equitable access to CKD care, even under the currently successful Universal Coverage scheme. As patients residing in rural areas are less likely to reach well-qualified personnel when compared with city dwellers [6], it is mandatory to seek other appropriate forms of renal care to delay CKD progression
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