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

Abstract

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.

Receipt of Nephrology Care and Clinical Outcomes Among Veterans With Advanced CKD

“…15 Conversely, in a recent analysis of patients in the Chronic Renal Insufficiency Cohort study with a mean eGFR of 45 ml/min/1.73m 2 , nephrology care was neither associated with slower progression of CKD, nor with more frequent attainment of guideline concordant care. 16 Similarly, a study from the National Kidney Foundation–Kidney Early Evaluation Program (NKF-KEEP) found no association between nephrology care and mortality in patients with CKD. 17 A limitation of these prior studies is that they did not account for the trajectory of kidney function.…”

Equanimity, Ambiguity, and the Physician’s Task

“…Ricardo et al report that among patients with mild-moderate renal insufficiency, prior nephrology specialty care was associated with more frequent treatment of chronic kidney disease complications and use of medications affecting the renin-angiotensin axis but not with long-term outcomes. 4 This study should not be taken to invalidate Osler's adulation for Ban intimate knowledge of the varied aspects of disease.^A sturdy body of evidence in fact supports the premise that specialists (including both nephrologists and psychiatrists) are more likely than generalists to deliver guidelineconcordant care on a condition-by-condition basis. The article likely signals something more subtle.…”

Chronic Kidney Disease: A Life Course Health Development Perspective

“…Numerous large clinical databases have been developed over the years that have allowed investigators to better understand the sociodemographic diversity associated with CKD development in adulthood. The Chronic Renal Insufficiency Cohort Study has published multiple articles (Ricardo et al 2015;Sandsmark et al 2015), and there are multiple excellent reviews available to better appreciate the relationships among risk factors for adult-onset CKD. Notably, the relationship between CKD and cardiovascular disease is complex and reciprocal.…”