The burden of comorbidity in people with chronic kidney disease stage 3: a cohort study

Abstract

BackgroundMultimorbidity is a growing concern for healthcare systems, with many countries experiencing demographic transition to older population profiles. Chronic kidney disease (CKD) is common but often considered in isolation. The extent and prognostic significance of its comorbidities is not well understood. This study aimed to assess the extent and prognostic significance of 11 comorbidities in people with CKD stage 3.MethodsA prospective cohort of 1741 people with CKD stage 3 was recruited from primary care between August 2008 and March 2010. Participants underwent medical history, clinical assessment, blood and urine sampling. Comorbidity was defined by self-reported doctor-diagnosed condition, disease-specific medication or blood results (hemoglobin), and treatment burden as number of ongoing medications. Logistic regression was used to identify associations with greater treatment burden (taking >5 medications) and greater multimorbidity (3 or more comorbidities). Kaplan Meier plots and multivariate Cox proportional hazards models were used to investigate associations between multimorbidity and all-cause mortality.ResultsOne thousand seven hundred forty-one people were recruited, mean age 72.9 +/−9 years. Mean baseline eGFR was 52 ml/min/1.73 m2. Only 78/1741 (4 %) had no comorbidities, 453/1741 (26 %) had one, 508/1741 (29 %) had two and 702/1741 (40 %) had >2. Hypertension was common (88 %), 30 % had ‘painful condition’, 24 % anemia, 23 %, ischaemic heart disease, 17 % diabetes and 12 % thyroid disorders. Median medication use was 5 medications (interquartile range 3–8) and increased with degree of comorbidity. Greater treatment burden and multimorbidity were independently associated with age, smoking, increasing body mass index and decreasing eGFR. Treatment burden was also independently associated with lower education status. After median 3.6 years follow-up, 175/1741 (10 %) died. Greater multimorbidity was independently associated with mortality (hazard ratio 2.81 (95 % confidence intervals 1.72–4.58), p < 0.001) for 3 or more comorbidities vs 0 or 1).ConclusionsIsolated CKD was rare and multimorbidity the norm in this cohort of people with moderate CKD. Increasing multimorbidity was associated with greater medication burden and poorer survival. CKD management should include consideration of comorbidities.

Non-dialysis dependent chronic kidney disease is associated with high total and out-of-pocket healthcare expenditures

“…The group with CKD defined by 585 ICD9 codes had the highest prevalence of high cholesterol, diabetes, and high blood pressure. Higher number of co-morbidities is associated with higher number of physician visits and medications utilized as documented in previous studies [8, 11, 15]. In fact, the majority of adults with moderate to severe CKD may have 3 or more co-morbid conditions and take at least 5 medications [11].…”

“…Only cancer patients had a higher average number of annual physician visits [14]. The total number of medications among adults with CKD may also be higher than most other chronic medical conditions with one study reporting that over 60% of adults with stage 3 CKD taking 5 or more different medications daily [11]. The high total number of physician visits and medications required for CKD care drives up total direct healthcare expenditures and likely also increases out-of-pocket expenditures, creating a financial burden for patients.…”

Chronic kidney disease: identification and management in primary care

“…CKD is an important noncommunicable condition and is a determinant of poor outcomes, often occurring alongside (and worsening the prognosis of) other noncommunicable disease 2–4,15–17. The risk of developing cardiovascular disease is greater than the risk of progression to end-stage kidney disease for the majority of people with CKD 11.…”

Chronic Kidney Disease: Exploring Value-Based Healthcare as a Potential Viable Solution

“…In particular, for chronic diseases, this is essential, where evidence clearly shows that continuity and patient engagement are 2 main sources for improved therapy adherence [57]. Specifically for CKD patients the integrative aspect is essential, as a variety of caregivers are involved: (1) due to the health system set up (a CKD patient is first usually seen by a general practitioner before co-treatment with a nephrologist is established), (2) the high pill burden for a patient and (3) the majority of CKD patients have co-morbidities and are being treated by other care providers than nephrologists [20,23,58]. Additionally, as a CKD patient will be on different treatment options in their life, it is therefore crucial to determine the right modality for the right patient at the right time in the right location [46].…”