Timely Referral Alone May Not Be Enough for Patients With Chronic Kidney Disease

Abstract

To the Editor: We read with great interest the review article on late referral (LR) of patients with chronic kidney disease (CKD) by Sprangers et al.1Sprangers B Evenepoel P Vanrenterghem Y Late referral of patients with chronic kidney disease: no time to waste.Mayo Clin Proc. 2006; 81: 1487-1494Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar As the authors pointed out, educating primary care physicians (PCPs) about optimal referral guidelines is important in preventing LR. However, what is equally important is PCPs' management of CKD itself. Late referral rates range from 10.5% to 83.0% of patients,1Sprangers B Evenepoel P Vanrenterghem Y Late referral of patients with chronic kidney disease: no time to waste.Mayo Clin Proc. 2006; 81: 1487-1494Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar and almost 40% of LRs are due to the reluctance of patients to visit a nephrologist.2Jungers P Zingraff J Albouze G et al.Late referral to maintenance dialysis: detrimental consequences.Nephrol Dial Transplant. 1993; 8: 1089-1093PubMed Google Scholar With an increasing incidence and prevalence of CKD, patients encounter long waiting times for nephrology consultation. Thus, PCPs should be familiar with and adhere to predialysis CKD management principles as proposed in the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines to enhance the quality of prereferral care.3National Kidney Foundation K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification, part 1: executive summary.Am J Kidney Dis. 2005; 39: S17-S30Google Scholar To investigate the quality of prereferral care of patients with CKD, we conducted a retrospective analysis of 204 patients who began dialysis for CKD between March 2003 and March 2005 in 2 community hospitals in Rochester, NY. Patients who had stage 3 and stage 4 CKD at referral were identified, and relevant clinical and laboratory data were obtained from the initial nephrology consultation notes. We used hemoglobin (>11 g/dL), serum calcium (8.4-10.2 mg/dL), and serum phosphorus (2.7-4.6 mg/dL) levels; calcium-phosphorus product (<55 mg2/dL2); and use of erythropoietic agents and angiotensin-converting enzyme inhibitors as measures for assessing the quality of predialysis care (values in parentheses indicate adequate care). Of the 204 patients who began dialysis treatment for CKD during the study period, 45 had stage 3 and 100 had stage 4 CKD at referral. In both groups, predialysis control of blood pressure; maintenance of hemoglobin, calcium, and phosphorus levels; and use of renoprotective agents and erythropoietic agents were suboptimal (Table 1). Thus, even though these patients were appropriately referred to nephrologists as specified by National Kidney Foundation guidelines (in stages 3 and 4), a large proportion had received suboptimal prereferral care that could impact long-term outcomes.TABLE 1Clinical and Laboratory Parameters in Patients With Stage 3 and 4 Chronic Kidney Disease at Referral for Dialysis*Values are presented as percentage of patients. ACE = angiotensin-converting enzyme; BP = blood pressure.ParameterStage 3Stage 4Systolic BP >130 mm Hg8085Hemoglobin <11 g/dL4147Serum calcium <8.4 g/dL2422Serum phosphorous >4.6 g/dL2425Calcium-phosphorous product >55 mg2/dL270Use of erythropoietins27Use of ACE inhibitors3522* Values are presented as percentage of patients. ACE = angiotensin-converting enzyme; BP = blood pressure. Open table in a new tab Approximately 4% of the US adult population has moderate to severe CKD4Coresh J Astor BC Greene T Eknoyan G Levey AS Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey.Am J Kidney Dis. 2003; 41: 1-12Abstract Full Text Full Text PDF PubMed Scopus (2301) Google Scholar (estimated glomerular filtration rate <60 mL/min per 1.73 m2 but not requiring dialysis), and PCPs have a key role in their management. With the widespread availability of guidelines and the emphasis given by insurance companies, PCPs' quality of care of patients with coronaryartery disease and diabetes has improved with angiotensin pathway inhibitors, β-blockers, aspirin, and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors. More initiatives should focus in a similar manner on educating PCPs about optimal management of hypertension, anemia, and bone mineral metabolism in patients with CKD. In addition, a shared nephrology clinic in which nephrologists evaluate patients remotely with use of routine biochemical tests and clinical data recorded by the PCP may improve the quality of care for these patients.5Jones C Roderick P Harris S Rogerson M An evaluation of a shared primary and secondary care nephrology service for managing patients with moderate to advanced CKD.Am J Kidney Dis. 2006; 47: 103-114Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar Presented as an abstract at the annual meeting of the American Society of Nephrology, San Diego, Calif, November 18, 2006.