Abstract
Primary kidney disease is suggested to affect renal prognosis of CKD patients; however, whether nephrology care modifies this association is unknown. We studied patients with CKD stage I-IV treated in a renal clinic and with established diagnosis of CKD cause to evaluate whether the risk of renal event (composite of end-stage renal disease and eGFR decline ≥40%) linked to the specific diagnosis is modified by the achievement or maintenance in the first year of nephrology care of therapeutic goals for hypertension (BP ≤130/80 mmHg in patients with proteinuria ≥150 mg/24h and/or diabetes and ≤140/90 in those with proteinuria <150 mg/24h and without diabetes) anemia (hemoglobin, Hb ≥11 g/dL), and proteinuria (≤0.5 g/24h). Survival analysis started after first year of nephrology care. We studied 729 patients (age 64±15 y; males 59.1%; diabetes 34.7%; cardiovascular disease (CVD) 44.9%; hypertensive nephropathy, HTN 53.8%; glomerulonephritis, GN 17.3%; diabetic nephropathy, DN 15.9%; tubule-interstitial nephropathy, TIN 9.5%; polycystic kidney disease, PKD 3.6%). During first year of Nephrology care, therapy was overall intensified in most patients and prevalence of main therapeutic goals generally improved. During subsequent follow up (median 3.3 years, IQR 1.9-5.1), 163 renal events occurred. Cox analysis disclosed a higher risk for PKD (Hazard Ratio 5.46, 95% Confidence Intervals 2.28–10.6) and DN (1.28,2.99–3.05), versus HTN (reference), independently of age, gender, CVD, BMI, eGFR or CKD stage, use of RAS inhibitors and achievement or maintenance in the first year of nephrology care of each of the three main therapeutic goals. No interaction was found on the risk of CKD progression between diagnostic categories and month-12 eGFR (P=0.737), as with control of BP (P=0.374), Hb (P=0.248) or proteinuria (P=0.590). Therefore, in CKD patients under nephrology care, diagnosis of kidney disease should be considered in conjunction with the main risk factors to refine renal risk stratification.
Highlights
The 2012 update of KDIGO (Kidney Disease: Improving Global Outcomes) guideline recommends considering the cause of kidney disease as modifier of CKD prognosis in addition to albuminuria and estimated glomerular filtration rate [1]
Mean age was around 50 years while most CKD patients referred to renal clinics are over 65 years [1,7], diabetic nephropathy was poorly or not represented at all while it is a main cause of CKD [8], and use of agents inhibiting the renin-angiotensin system (RAS), currently considered as the first-choice drugs in CKD, was not mentioned or limited to a minority of patients
The study, hardly allows to estimate the renal risk associated with each specific diagnosis in the “real world” of tertiary nephrology care because investigators excluded patients with coronary artery disease that account for a substantial quote of contemporary patient population in renal clinics [1,7], and no information was provided on length and efficacy of nephrology intervention prior to the start of survival analysis
Summary
The 2012 update of KDIGO (Kidney Disease: Improving Global Outcomes) guideline recommends considering the cause of kidney disease as modifier of CKD prognosis in addition to albuminuria and estimated glomerular filtration rate (eGFR) [1]. Studies on renal prognosis have shown that albuminuria level is or more predictive than the cause of CKD [3,4,5,6] These studies examined patients in the early 90’s, being poorly informative for today practice. From our outpatient clinic dedicated to CKD-ND, we selected patients with diagnosed primary renal disease to evaluate whether renal prognosis linked to the specific cause of CKD changes according to the degree of control of hypertension, proteinuria and anemia, that have been identified as the main modifiable determinants of renal events [1,7,10,11,12,13,14]
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