Kidney Disease In Primary Care Research Articles

Improving the management of chronic kidney disease in primary care by enhancing laboratory reports with additional information and follow-up procedures

Identifying people at risk for progressive chronic kidney disease and connecting them with recommended care is crucial for providing timely and optimal treatment. The ASSIST-CKD (A programme to Spread eGFR [estimated glomerular filtration rate] graph Surveillance for the early identification, Support and Treatment of people with progressive CKD [chronic kidney disease]) trial evaluated the effect of graphical eGFR reporting to primary care physicians on late presentation to a nephrologist in the United Kingdom. Trial data were obtained from the UK Renal Registry. Although the results were neutral, the data generated from the ASSIST-CKD trial are informative and provide useful estimates of the intervention effect. The trial also provides valuable insights into the challenges of implementing complex interventions in busy health care environments, which can be used to guide the designs of future interventions.

Detecting and managing the patient with chronic kidney disease in primary care: A review of the latest guidelines.

Chronic kidney disease (CKD) is a major global health problem, affecting about 9.5% of the population and 850 million people worldwide. In primary care, most CKD is caused by diabetes and/or hypertension, but a substantial proportion of cases may have alternative causes. During the early stages, CKD is asymptomatic, and many people are unaware that they are living with the disease. Despite the lack of symptoms, CKD is associated with elevated risks of cardiovascular disease, progressive kidney disease, kidney failure and premature mortality. Risk reduction strategies are effective and cost-effective but require early diagnosis through testing of the estimated glomerular filtration rate and albuminuria in high-risk populations. Once diagnosed, the treatment of CKD centres around lifestyle interventions, blood pressure and glycaemic control, and preventative treatments for cardiovascular disease and kidney disease progression. Most patients with CKD should be managed with statins, renin-angiotensin-aldosterone system inhibitors and sodium-glucose cotransporter-2 inhibitors. Additional treatment options to reduce cardiorenal risk are available in patients with diabetes, including glucagon-like peptide-1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists. The Kidney Failure Risk Equation is a new tool that can support the identification of patients at high risk of progressive kidney disease and kidney failure and can be used to guide referrals to nephrology. This review summarizes the latest guidance relevant to managing adults with, or at risk of, CKD and provides practical advice for managing patients with CKD in primary care.

Optimising diagnosis and management of kidney disease: an implementation trial of a clinical decision support system future health today

BackgroundChronic kidney disease affects more than 10% of the world’s population and is a non-communicable disease of global concern and priority. There is a significant implementation gap between best practice guideline recommendations and current kidney disease management. Previous research has shown the need to partner with primary care to improve education, collaboration, and kidney disease awareness. This implementation trial will explore use of an innovative clinical decision support software, Future Health Today, to improve screening, diagnosis, and management of kidney disease in primary care. The program will be supported by tertiary care outreach services. The primary aim is to test the hypothesis that the Future Health Today implementation program will improve screening, diagnosis, and management of kidney disease. Secondary aims are to evaluate primary care satisfaction and broader health service impacts.MethodsThis pre-post implementation trial using an interrupted time series design will evaluate the clinical and service outcomes of Future Health Today, using a mixed methods study in twenty general practices with an estimated population size of 150,000. Deidentified patient data will be extracted from participating practices to examine the primary aims of the study. Surveys and semi-structured interviews with general practice will inform secondary hypotheses. Data linkage between primary care and tertiary care data will examine the broader health service impacts.DiscussionThis investigator driven trial will assess the impact of Future Health Today software coupled with education and clinical outreach support. Investigators hypothesise that there will be improvement in appropriate screening, diagnosis, and management of kidney disease. This program has the potential to be scaled more broadly.Trial RegistrationAustralian New Zealand Clinical Trial Registry: ACTRN12623001096640.

Management of chronic kidney disease in primary care: New practical guidelines in primary care

Chronic kidney disease is often encountered in clinical practice, affecting between 8 and 16% of the world's population. Screening for CKD represents a major challenge for patients, given the increase in morbidity and mortality associated with the disease, as well as a public health issue in terms of slowing the progression to end-stage renal failure, which requires costly replacement treatments (dialysis and transplantation). The new KDIGO guidelines suggest aiming for optimal control of the cardiovascular risk factors associated with chronic kidney disease, in particular with the help of emerging treatments such as SGLT2 inhibitors. This article summarises the latest nephroprotection recommendations for primary care physicians.

National technical guidelines for the prevention and treatment of diabetic kidney disease in primary care (2023)

Diabetic kidney disease (DKD) is one of the major chronic complications of diabetes and is associated with a heavy disease burden. Since the release of the National Guidelines for the Prevention and Control of Diabetes in Primary Care (2018), there has been continuous improvement in the basic public health services and basic medical services of the primary care setting and an expansion of the scope of work. Therefore, more detailed technical guidelines for the prevention and management of diabetes and its complications in primary care are needed. This guide aims to promote the standardization of DKD prevention and control in primary care, to assist primary care physicians with the prevention and control of DKD, and to ensure the comprehensive management of patients with DKD. The contents include the basic requirements for the management, overview, screening, diagnosis and staging, treatment, follow-up, and referral of patients with DKD.

Telenephrology Dashboard for Active Surveillance of Kidney Disease in Primary Care: A Quality Improvement Initiative

Telenephrology Dashboard for Active Surveillance of Kidney Disease in Primary Care: A Quality Improvement Initiative

Chronic kidney disease in primary care: risk of cardiovascular events, end stage kidney disease and death

BackgroundThe prevalence of chronic kidney disease (CKD) is increasing globally. Early diagnosis in primary care may have a role in ensuring proper intervention. We aimed to determine the prevalence and outcome of CKD in primary care.MethodsWe performed an observational cohort study in primary care in Copenhagen (2001–2015). Outcomes were stroke, myocardial infarction (MI), heart failure (HF), peripheral artery disease (PAD), all-cause- and cardiovascular mortality. We combined individuals with normal kidney function and CKD stage 2 as reference. We conducted cause-specific Cox proportional regressions to calculate the hazard ratios for outcomes according to CKD group. We explored the associations between kidney function and the outcomes examined using eGFR as a continuous variable modelled with penalised splines. All models were adjusted for age, gender, diabetes, hypertension, existing CVD, heart failure, LDL cholesterol and use of antihypertensive treatment.ResultsWe included 171,133 individuals with at least two eGFR measurements of which the majority (n = 157,002) had eGFR > 60 ml/min/1.73m2 at index date, and 0.05% were in CKD stage 5. Event rates were low in eGFR > 60 ml/min/1.73m2 but increased in those with higher stages of CKD. In adjusted analyses we observed an increase in hazard rates for every outcome with every increment in CKD stage. Compared to the reference group, individuals in CKD stage 4 had double the hazard rate of PAD, MI, cardiovascular and all-cause mortality.ConclusionsOur data from a large primary care cohort demonstrate an early increase in the risk of adverse outcomes already at CKD stage 3. This underlines the importance of studying early intervention in primary care.

Step-Wise Management of Anemia in Patients With Chronic Kidney Disease in Primary Care: Qualitative Study.

Anemia is common in chronic kidney disease (CKD) and is associated with increased cardiovascular risk and reduced quality of life, but is often sub-optimally managed. Most patients are managed in primary care alongside other comorbidities. Interventions to improve the management of anemia in CKD in this setting are needed. We conducted a qualitative study to evaluate how an audit-based education (ABE) intervention might improve the management of anemia in CKD. We explored outcomes that would be relevant to practitioners and patients, that exposed variation of practice from National Institute for Health and Care Excellence (NICE) guidelines, and whether the intervention was feasible and acceptable. Practitioners (n = 5 groups) and patients (n = 7) from 4 London general practices participated in discussions. Practitioners welcomed the evidence-based step-wise intervention. However, prescribing erythropoiesis-stimulating agents (ESAs) was felt to be outside of their scope of practice. There was a gap between NICE guidance and clinical practice in primary care. Iron studies were not well understood and anemia management was often conservative or delayed. Patients were often unaware of having CKD, and were more concerned about their other comorbidities, but largely trusted their GPs to manage them appropriately. The first steps of the intervention were welcomed by practitioners, but they expressed concerns about independently prescribing ESAs. Renal physicians and GPs could develop shared care protocols for ESA use in primary care. There is scope to improve awareness of renal anemia, and enhance knowledge of guideline recommendations; and our intervention should be modified accordingly.

Appropriateness of drug prescriptions in patients with chronic kidney disease in primary care: a double-center retrospective study

BackgroundChronic kidney disease (CKD) is a highly prevalent disease worldwide. A basic pillar for the management of a patient with CKD is the safe use of drugs. Inadequate dosing of medication or contraindicated drugs in renal impairment can lead to negative outcomes. The primary objective was to analyse the drug prescriptions of patients with CKD from two primary care centres to see if they were optimally adapted to the patient's estimated glomerular filtration rate (eGFR).MethodsA retrospective observational study was conducted in two urban primary care centres. The study period was between September–October 2019. Patients over 18 years of age, with established CKD and with an eGFR less than 60 mL/min/1.73m2 for at least three months were included. Their demographic data (age and sex) and clinical variables such as associated comorbidities, eGFR value were retrospectively registered. Finally, their medication plans were reviewed in order to detect: inappropriate prescribing (IP), defined as an incorrect dose/frequency or contraindicated drug according to the renal function of the patient; nephrotoxic drugs and drugs with a high sodium content.ResultsA total of 273 patients were included. The most common patient profile was an elderly woman, polymedicated, with other concomitant diseases and with mild CKD. Two hundred and one IPs were detected, 13.9% of which were contraindicated drugs. Of all patients, 49.1% had been prescribed at least one IP on their medication plan, 93.8% had some potentially nephrotoxic drug and 8.4% had drugs with a high sodium content prescribed.ConclusionsPatients with CKD are at increased risk of medication-related problems. It is necessary to implement measures to improve the safety in the prescription of drugs in patients with CKD.

Self-rated knowledge and competence regarding the management of chronic kidney disease in primary care: A cross-sectional European survey of primary care professionals

BackgroundDiabetes is a major risk factor for chronic kidney disease (CKD), which is a leading cause of global morbidity and mortality and also associated with substantial costs to healthcare systems. Despite the current best practice standards of care, management of CKD in diabetes in the primary care setting remains an ongoing challenge. Using an online survey, we aimed to assess the self-rated knowledge and competence of primary care professionals involved in the management of CKD in diabetes in the European region. MethodsAn online anonymous survey was developed by the Primary Care Diabetes Europe research group and administered to primary care professionals involved in managing CKD in diabetes from 23rd March 2022–9 th October 2022. Descriptive statistics were used to summarise questionnaire responses. Factors influencing ability to initiate treatment strategies were evaluated using logistic regression. ResultsA total of 266 respondents (51.9% males) completed the questionnaire. Most respondents were GPs (82.7%) followed by nurses (9.4%). The age of respondents ranged from 25 to 72 years with a median of 51 years. About a third of respondents indicated that they were fully confident in the screening and diagnosis of CKD in diabetes. With regards to CKD presentation, staging and prognosis, 16.5–21.8% of respondents stated they were fully confident in this area; however, about 11% of respondents were not confident on how to predict CKD prognosis using established clinical guidelines. About a third of respondents stated they were confident without support regarding the complications of kidney disease in diabetes and it being a risk multiplier; just a quarter of respondents were fully confident. A third of respondents stated they were fully confident regarding appropriate management strategies for preventing or slowing down the progression of CKD and the initiation of newer agents. In multivariable analyses, confidence in the knowledge of the stages of kidney disease and criteria for the diagnosis of kidney disease were each associated with an increased odds in the confidence to select and initiate appropriate management strategies. ConclusionsWith regards to almost all aspects of management of CKD in diabetes, only up to a third of primary care professionals stated they are fully confident and are able to teach others; the majority are confident but would like to know more or require extra support. This may be a contributor to the challenges faced in providing optimal CKD care in people with diabetes in the primary care setting. Effective interventions that can promote the uptake of best practice clinical guidelines in primary care are urgently needed.

Associations and mitigations: an analysis of the changing risk factor landscape for chronic kidney disease in primary care using national general practice level data

ObjectivesEarly recognition of chronic kidney disease (CKD) should be achieved by every modern healthcare system. The objective of this study was to investigate CKD risk factor trends in England using...

Use of SGLT-2 Inhibitors to Treat Chronic Kidney Disease in Primary Care.

Chronic kidney disease (CKD) remains underrecognized by patients and clinicians in the primary care setting, largely due to its asymptomatic presentation in early stages. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have demonstrated kidney-protective effects in clinical trials-including in patients with and without type 2 diabetes (T2D)-and there are several proposed mechanisms for these benefits. Dapagliflozin and canagliflozin are SGLT2 inhibitors with indications for CKD, and only dapagliflozin is indicated for CKD in patients without T2D. Clinically relevant adverse events associated with SGLT-2 inhibitors include volume depletion, diabetic ketoacidosis, and genital mycotic infections.

MO518: Chronic Kidney Disease in Primary Care and the Risk of Cardiovascular Comorbidity and Mortality

Abstract BACKGROUND AND AIMS The prevalence of chronic kidney disease (CKD) is increasing globally. Often, the condition develops silently over time, with no or only a few symptoms in earlier stages. Therefore, early recognition in primary care may have an important role in ensuring diagnosis and proper intervention. We aimed to determine the prevalence and outcome of CKD in a large primary care cohort in Denmark. METHOD We performed an observational cohort study using data from individuals above age 40 followed in primary care in the greater Copenhagen area between 2000 and 2015 and linked them to Danish health registries. A run-in period of 3 months was included to ensure stable conditions and rule out acute changes in eGFR at baseline. The date of the second measurement of eGFR during the study period was considered the subject's index date (baseline). Outcomes were relevant diagnoses such as stroke, myocardial infarction (MI), hospitalisations for heart failure (HHF) and peripheral artery disease (PAD) (last update 2018), all-cause mortality and cardiovascular mortality. Kidney function (eGFR) was estimated by the CKD-EPI formula based on serum creatinine and expressed in mL/min/1.73 m2. Conventional CKD groups are used with CKD 1 and 2 (normal—eGFR > 60 mL/min/1.73 m2) as reference groups for the hazard ratio estimates. Outcomes were presented as the number of events/100 person-years (PY). We conducted survival (all-cause mortality outcome) and competing risk (rest of the outcomes) analyses using the Cox proportional hazards model to calculate the (cause-specific) hazard ratios for the outcomes according to CKD group. We further explored the continuous associations between kidney function and the outcomes examined by using eGFR as a continuous variable with penalised splines. All models were adjusted for known risk factors (age, gender, diabetes, hypertension, existing CVD, heart failure, LDL cholesterol, use of antihypertensive treatment). RESULTS We included a population of 171 133 individuals. As expected, the majority (n = 157002) was in CKD 1 or 2 at the index date, and only a small proportion (0.05%) was in CKD stage 5. In general, event rates were low in CKD stages 1 and 2 and rose with higher stages of CKD. In the adjusted analyses, we observed a stepwise increase in hazard rates for every outcome with every increment in CKD stage (Fig. 1). This was confirmed by the continuous analysis. Compared with CKD stage 1 + 2, individuals in CKD stage 4 had approximately double the hazard rate of PAD, MI, cardiovascular and all-cause mortality. CONCLUSION Our data from a large primary care cohort demonstrate an early increase in risk for adverse outcomes already at CKD stage 3. This provides the basis and underlines the importance of studying early intervention in primary care.

A practical approach to chronic kidney disease in primary care.

Chronic kidney disease (CKD), a common clinical problem in primary care, can be defined as any abnormality of the kidney structure and/or function that has been present for at least 3 months. Over the past 20 years, the incidence and prevalence of CKD have been increasing in Malaysia in line with the rising number of non-communicable diseases. At present, CKD has no cure. The treatment of CKD is very much dependent on early diagnosis and prevention of CKD progression. In this article, we aim to illustrate a practical approach to CKD in primary care, including diagnosis, evaluation, and management of CKD.

Evaluation of health-promoting self-care behaviors in hypertensive patients with concomitant chronic kidney disease in primary care

This study was to investigate the relationships among health behaviors and quality of life (QOL) and to test a proposed model among people with hypertension and concomitant chronic kidney disease (CKD) in primary care. In addition, the mediation effect of modifiable risk factors between self-care health behaviors and QOL was examined. This study was prospective, conducted in the centers of primary medical care in the period from January 2018 to January 2020. In total, 170 patients diagnosed with hypertension and CKD at least 12 months previously were included in this study. The following parameters were measured: self-efficacy, self-care health behaviors with the subscales of health responsibility, exercise, consumption of a healthy diet, stress management, and smoking cessation; modifiable risk score; and QOL (assessed using the 36-item Short-Form Health Survey instrument). Self-efficacy had a significantly positive direct effect on self-care health behaviors, with a standardized regression coefficient of 0.87 (P = 0.007), a negative indirect effect on risk factors, with a standardized regression coefficient of 0.11 (P = 0.006), and a positive indirect effect on QOL, with a standardized regression coefficient of 0.62 (P = 0.008). Self-care health behaviors had a significantly positive direct effect on QOL, with a standardized regression coefficient of 0.72 (P = 0.012); there was also an indirect effect of 0.053 (P = 0.004). The direct effect of risk factors on QOL was significant, with a standardized regression coefficient of 0.44 (P = 0.018). The direct effect of self-care health behaviors on QOL was 0.77 (P = 0.008), which has been reduced to 0.72 (P = 0.012). The reduced effect of 0.05 was significant (P = 0.004), confirming the mediating role of modified risk factors. This study indicates health-promoting behaviors in hypertensive patients with CKD have a potential impact on their QOL in primary care. Primary care physicians should focus on motivation strategies to encourage individuals to perform self-care health-promoting behaviors associated with the improved QOL, in order to achieve better outcomes in risk factor management.

Step-Wise Management of Anaemia in People with Chronic Kidney Disease in Primary Care: Qualitative Study

Step-Wise Management of Anaemia in People with Chronic Kidney Disease in Primary Care: Qualitative Study

The association of blood pressure variability with adverse outcomes in a primary care chronic kidney disease cohort.

Hypertension is common in individuals with chronic kidney disease and both conditions are associated with adverse outcomes including cardiovascular morbidity. Therefore, it is clinically important to identify methods of risk prediction in individuals with chronic kidney disease. Blood pressure variability has recently emerged as a predictor of cardiovascular events and mortality in the general population, with growing evidence indicating that it may play a similar role in individuals with chronic kidney disease. However, there have been no large studies assessing blood pressure variability in individuals with chronic kidney disease in primary care, where the majority of these patients are managed. Using a retrospective observational study design, we analyzed routinely collected blood pressure readings from 16 999 individuals in The Leicester and County Chronic Kidney Disease cohort. Standard deviation, coefficient of variation and average real variability of SBP were used to calculate blood pressure variability. During a median follow-up of 5.0 (IQR 3.3--5.0) years, 2053 (12.1%) patients had cardiovascular events, death occurred in 5021 (29.6%) individuals and 156 (0.9%) individuals had endstage kidney disease events. In adjusted models, standard deviation and coefficient of variation were associated with cardiovascular events, all-cause mortality and endstage kidney disease. Average real variability was associated with all-cause mortality and cardiovascular events, but not endstage kidney disease. Blood pressure variability may be an accessible, routinely collected, noninvasive measure for stratifying the risk of adverse events in individuals with chronic kidney disease in a primary care setting.

Non-dialysis chronic kidney disease in primary care - a questionnaire study among general practitioners

Zusammenfassung Einleitung Die Mehrheit der von nicht dialysepflichtiger, chronischer Niereninsuffizienz betroffenen Patienten wird von Hausärzten betreut. Die Datenlage auf diesem Gebiet ist besonders in Deutschland lückenhaft. Ziel der Umfrage war es, die wahrgenommene Häufigkeit in der hausärztlichen Praxis, die Nutzung von Diagnostik und Therapie sowie verwendete Hilfsmittel unter Berücksichtigung des beruflichen Hintergrunds und der Erfahrung der antwortenden Hausärzte abzuschätzen. Methoden In Kooperation mehrerer Fachrichtungen wurde ein selbstentwickelter, diagnosespezifischer Fragebogen erstellt. Dieser wurde an 1130 Hausärzte aus Sachsen und Sachsen-Anhalt, die zufällig ausgewählt wurden, per Post versandt. Die Datenerhebung erfolgte von Juni 2019 bis Juli 2019. Ergebnisse Von 1130 versandten Fragebögen wurden 372 auswertbar zurückgesandt (Rücklaufquote: 32,9 %). Die Häufigkeit der nicht dialysepflichtigen, chronischen Niereninsuffizienz wurde auf 6–15 % geschätzt. Der Einstellung von Bluthochdruck und Diabetes mellitus messen 97 % der befragten Ärzte eine hohe bis sehr hohe Priorität bei. Zur Proteinurie-Diagnostik wurde die Nutzung von Urinteststreifen von 60,8 %, die Anforderung einer Albumin-Kreatinin-Ratio von 22,6 % der Befragten angegeben. Nur geringe Differenzen konnten im Antwortverhalten der teilnehmenden Arztgruppen offengelegt werden. Die Berufserfahrung ist bei der Wahl der Hilfsmittel, im Besonderen Leitlinien, ein wichtiger Einflussfaktor. Diskussion Die Ergebnisse zeigen, dass die Angaben und Prioritäten der befragten Ärzte in hohem Maße mit den internationalen Empfehlungen zur Versorgung niereninsuffizienter Patienten korrelieren. Verbesserungen im Bereich der Progressionsdiagnostik sind möglich und nötig. Allgemeinmediziner und hausärztliche Internisten besitzen ein vergleichbares Kompetenzniveau in der primärärztlichen Versorgung der nicht dialysepflichtigen, chronischen Niereninsuffizienz. Kernaussagen: Hausärzte schätzen die Prävalenz von nicht dialysepflichtiger, chronischer Niereninsuffizienz in ihrer Praxis auf 6–15 %.Die Albumin-Kreatinin-Ratio wird zur Proteinurie-Diagnostik gegenüber dem Urinstreifentest zu selten angefordert.Praktische Ärzte, Fachärzte für Allgemeinmedizin und hausärztlich tätige Internisten haben ein vergleichbares Kompetenzniveau bei der Versorgung von Patienten mit nicht dialysepflichtiger, chronischer Niereninsuffizienz.Die Berufserfahrung ist bei der Wahl der Hilfsmittel, im Besonderen Leitlinien, ein wichtiger Einflussfaktor.

Management of chronic kidney disease: perspectives of Brazilian primary care physicians.

To investigate primary care physicians' knowledge of and attitudes toward care for chronic kidney disease patients. In Brazil, care for chronic kidney disease, a global public health problem, is provided by the Brazilian National Health System, which is organized around primary care. The study aimed to investigate the knowledge and attitudes of primary care physicians about the management of chronic kidney disease. This research is based on quantitative and qualitative data. The participants were 92 physicians from 81 primary care units located in eight cities of the São Paulo/Brazil health region, who answered a self-administered questionnaire. Only 59% and 58% of the physicians recognized smoking and obesity, respectively, as risk factors for chronic kidney disease. Health appointments and drug therapy predominated as disease prevention strategies and less than 30% mentioned multiprofessional care and health education groups. For early diagnosis, isolated serum creatinine was the most used test and 64.6% stated they classified the disease stages. Exclusive follow-up in primary care decreased from 79% in stage 1 to 19.5% in stage 3B and the patients' monitoring in the healthcare network varied from 8.7% in stage 1 to 70.6% in stages 4 and 5ND, suggesting early referrals and lack of referral at the necessary stages. Access to information on the referred patient was, predominantly, through the patient's report and 74% of the physicians did not have matrix support regarding chronic kidney disease. The study showed that the healthcare teams need to update their knowledge and procedures to be able to provide a comprehensive and efficient approach to treating chronic kidney disease in primary care.

Making Sense of Chronic Kidney Disease in Primary Care – Identification, Evaluation and Monitoring

Making Sense of Chronic Kidney Disease in Primary Care – Identification, Evaluation and Monitoring