Abstract
Chronic Kidney Disease (CKD) prevention programs allow to control morbidity and/or delay renal replacement therapy. The design of a CKD prevention program is described, including highlights on how the primary and secondary levels of care interact with each other through the characterization of the population admitted for secondary prevention. The description of the program was based on a literature review. Descriptive statistics were used to characterize the patients participating in the program. The design and implementation of the prevention program was based on the integration of service networks and care levels. The main activities for the program were detailed according to the care level in which they performed. 3 487 patients in total were admitted for control at the second care level due to an estimated glomerular filtration rate of <60 mil/min; 87.81% of the patients were admitted with CKD stage 3 and a median glomerular filtration rate of 46.21mil/min. The main causes of CKD were hypertension and diabetes. On admission, 2 129 patients (61.05 %) had systolic blood pressure <140 mmHg and 3 091 (88.64 %) had diastolic blood pressure <90 mmHg; 357 (57.58 %), out of 620, diabetic patients with glycosylated hemoglobin presented values <7.5 %. A prevention program was designed and implemented to allow the integration of care levels oriented to a multidisciplinary intervention, which ultimately managed to recognize patients and to give continuity to care provision for a better control of CKD.
Highlights
A prevention program was designed and implemented to allow the integration of care levels oriented to a multidisciplinary intervention, which managed to recognize patients and to give continuity to care provision for a better control of Chronic Kidney Disease (CKD)
Primary care-based disease management of chronic kidney disease (CKD), based on estimated glomerular filtration rate (eGFR) reporting, improves patient outcomes
Summary
The design and implementation of the prevention program was based on the integration of service networks and care levels. Se describe la población incluida en el programa, cuyos criterios son: ser de mayor de 18 años, con estadios 3, 4 y 5 de la ERC, admitida para prevención secundaria en el segundo nivel de atención. D. Intervención temprana de los pacientes con ERC en estadios iniciales y/o remisión al segundo nivel de atención: el programa define que los pacientes clasificados en los estadios 1 y 2 de la ERC son intervenidos en el primer nivel de atención, por un equipo conformado por médico general, enfermera, gestor de autocuidado y educador, que en coordinación con el equipo del segundo nivel de atención, de acuerdo a la enfermedad de base y al riesgo de progresión, definen un plan de manejo y unas metas clínicas para el control de la enfermedad. Frecuencia de atención en el segundo nivel de atención según el estadio de la ERC y la tasa de filtración glomerular estimada
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