Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease

Jones, Chris; Roderick, Paul; Harris, Scott; Rogerson, Mary

doi:10.1093/ndt/gfl198

Cited by 132 publications

(121 citation statements)

References 48 publications

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“…30 In contrast, three small studies conducted outside the U.S. found nephrology care to be associated with better kidney function preservation. [12][13][14] In two separate studies of U.S. Veterans with CKD, nephrology care was associated with a reduced risk of death, and regular frequent visits were associated with the lowest risk. 10,11 A potential explanation for these heterogeneous findings is that patients with severe terminal medical conditions (e.g.…”

Section: Discussionmentioning

confidence: 99%

“…While a few existing studies have noted that adherence to clinical guidelines is suboptimal overall, 31,32 nephrology care has been generally associated with better control of hypertension, anemia, and calcium-phosphorus metabolism. [12][13][14][33][34][35] However, others have not observed a benefit of nephrology care on these parameters and have found such care to vary substantially among nephrologists. 11,36 Several reasons may account for our observations.…”

Section: Discussionmentioning

confidence: 99%

“…Several studies have shown that outpatient nephrology care may result in slowing kidney function decline and/or improving survival. [10][11][12][13][14] However, these reports are limited by small sample sizes, lack of racial/ ethnicity diversity, retrospective design or short duration of follow-up. The purpose of this study was to characterize current patterns of nephrology care and to examine the effect of nephrology care on management of CKD risk factors and complications, CKD progression, incident cardiovascular disease (CVD), and death among Chronic Renal Insufficiency Cohort (CRIC) Study participants.…”

Section: Introductionmentioning

confidence: 99%

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Influence of Nephrologist Care on Management and Outcomes in Adults with Chronic Kidney Disease

et al. 2015

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BACKGROUND: Predialysis nephrology care for adults with late stage chronic kidney disease (CKD) is associated with improved outcomes. Less is known about the effects of nephrology care in earlier stages of CKD. OBJECTIVE: We aimed to evaluate the effect of nephrology care on management of CKD risk factors and complications, CKD progression, incident cardiovascular disease (CVD), and death. DESIGN: This was a prospective cohort study. PARTICIPANTS: Participants included 3855 men and women aged 21 to 74 years enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study with a mean (SD) estimated glomerular filtration rate (eGFR) at entry of 45 (17) ml/min/1.73 m 2 , followed for a median of 6.6 years. MAIN MEASURES: The main predictor was self-reported prior contact with a nephrologist at study enrollment. Outcomes evaluated included CKD progression (≥ 50 % eGFR loss or end-stage renal disease), incident CVD, and death. RESULTS: Two-thirds (67 %) of the participants reported prior contact with a nephrologist at study enrollment. They were younger, more likely to be male, non-Hispanic white, and had lower eGFR and higher urine protein (p < 0.05). A subgroup with eGFR 30-< 60 ml/min/1.73 m 2 and prior contact with a nephrologist were more likely to receive pharmacologic treatment for CKD-related complications and to report angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use. After propensity score matching (for reporting prior contact with a nephrologist vs. not) and adjusting for demographic and clinical variables, prior contact with a nephrologist was not significantly associated with CKD progression, incident CVD or death (p > 0.05). CONCLUSIONS: One-third of CRIC participants had not seen a nephrologist before enrollment, and this prior contact was subject to age, sex, and ethnic-related disparities. While prior nephrology care was associated with more frequent treatment of CKD complications and use of ACEi/ARB medications, there was neither an association between this care and achievement of guidelinerecommended intermediate measures, nor long-term adverse outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Influence of Nephrologist Care on Management and Outcomes in Adults with Chronic Kidney Disease

et al. 2015

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“…In the last two decades, several uncontrolled or retrospective studies have underlined the clinical and economic advantages of timely referral to nephrology (20)(21)(22)(23). However, as highlighted by current guidelines (4), the referral recommendations still remain inconsistent.…”

Section: Discussionmentioning

confidence: 99%

Risk of ESRD and Death in Patients with CKD Not Referred to a Nephrologist

Minutolo

Lapi

Chiodini

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives Rising prevalence of CKD requires active involvement of general practitioners to limit ESRD and mortality risk. However, the outcomes of patients with CKD exclusively managed by general practitioners are ill defined. Results Overall 64% of patients were in stage 3a, and 4.5% of patients were in stages 3b-5. Patients with stages 1 and 2 were younger, were predominantly men, more frequently had diabetes, and had lower prevalence of previous cardiovascular disease than patients with stages 3a-5. Hypertension was frequent in all CKD stages (80%-94%), whereas there was a lower prevalence of dyslipidemia, albuminuria, and obesity associated with more advanced CKD. During the follow-up (median=7.2 years; interquartile range=4.7-7.7), 6592 patients died and 295 started ESRD. Compared with stages 1 and 2 (reference), mortality risk (hazard ratio, 95% confidence interval) was higher in stages 3b-5 (1.66, 1.49-1.86, 2.75, 2.41-3.13 and 2.54, 2.01-3.22, respectively) but not stage 3a (1.11, 0.99-1.23). Similarly, ESRD risk (hazard ratio, 95% confidence interval) was not higher at stage 3a (1.44, 0.79-2.64) but was greater in stages 3b-5 (11.0, 6.3-19.5, 91.2, 53.2-156.2 and, 122.8, 67.9-222.0, respectively). Among modifiable risk factors, anemia and albuminuria significantly predicted either outcome, whereas hypertension only predicted mortality.Conclusions In patients with CKD not referred to nephrology, risks of ESRD and mortality were higher in those with CKD stages 3b-5.

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“…The coordinated effort among the different specialties; primary care provider, endocrinologist and nephrologist remains crucial for optimal patient outcomes. Early referral to nephrologists has been found to be associated with decreased rates of decline in GFR 141 and mortality. 142 In spite of that, it is still not uncommon for CKD patients to be seen by a nephrologist for the first time only one month before starting dialysis.…”

Section: Early Referral To Nephrologistmentioning

confidence: 99%

Therapeutic Modalities in Diabetic Nephropathy: Standard and Emerging Approaches

et al. 2011

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Diabetes mellitus is the leading cause of end stage renal disease and is responsible for more than 40% of all cases in the United States. Current therapy directed at delaying the progression of diabetic nephropathy includes intensive glycemic and optimal blood pressure control, proteinuria/albuminuria reduction, interruption of the renin-angiotensin-aldosterone system through the use of angiotensin converting enzyme inhibitors and angiotensin type-1 receptor blockers, along with dietary modification and cholesterol lowering agents. However, the renal protection provided by these therapeutic modalities is incomplete. More effective approaches are urgently needed. This review highlights the available standard therapeutic approaches to manage progressive diabetic nephropathy, including markers for early diagnosis of diabetic nephropathy. Furthermore, we will discuss emerging strategies such as PPAR-gamma agonists, Endothelin blockers, vitamin D activation and inflammation modulation. Finally, we will summarize the recommendations of these interventions for the primary care practitioner.

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Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease

Abstract: Following nephrology referral, GFR decline slowed significantly and was associated with better survival. Earlier detection of patients with progressive CKD and interventions to slow progression may have benefits on both kidney and patient survival.

Cited by 132 publications

References 48 publications

Influence of Nephrologist Care on Management and Outcomes in Adults with Chronic Kidney Disease

Influence of Nephrologist Care on Management and Outcomes in Adults with Chronic Kidney Disease

Risk of ESRD and Death in Patients with CKD Not Referred to a Nephrologist

Therapeutic Modalities in Diabetic Nephropathy: Standard and Emerging Approaches

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