Recognition and Management of Chronic Kidney Disease in an Elderly Ambulatory Population

Abstract

BACKGROUND: Chronic kidney disease (CKD) is a growing problem among the elderly. Early detection is considered essential to ensure proper treatment and to avoid drug toxicity, but detection is challenging because elderly patients with CKD often have normal serum creatinine levels. We hypothesized that most cases of CKD in the elderly would go undetected, resulting in inappropriate prescribing. OBJECTIVE:To determine whether recognition of CKD is associated with more appropriate treatment DESIGN: Retrospective chart review PARTICIPANTS: All patients aged ≥65 years with a measured serum creatinine in the past 3 years at 2 inner city academic health centers.MEASUREMENTS: Estimated glomerular filtration rate (eGFR) calculated using the Modified Diet in Renal Disease equation, and for patients with eGFR<60, documentation of CKD by the provider, diagnostic testing, nephrology referral and prescription of appropriate or contraindicated medications. RESULTS:Of 814 patients with sufficient information to estimate eGFR, 192 (33%) had moderate (eGFR< 60 mL/min) and 5% had severe (eGFR<30 mL/min) CKD. Providers identified 38% of moderate and 87% of severe CKD. Compared to patients without recognized CKD, recognized patients were more likely to receive an ACE/ARB (80% vs 61%, p=.001), a nephrology referral (58% vs 2%, p<.0001), or urine testing (75% vs 47%, p<.0001), and less likely to receive contraindicated medications (26% vs 40%, p=.013). CONCLUSIONS:Physicians frequently fail to diagnose CKD in the elderly, leading to inappropriate treatment. Efforts should focus on helping physicians better identify patients with low GFR.

Chronic kidney disease management in an academic internal medicine clinic

“…In a study of Italian general practitioners, only 15.2% of patients with eGFR less than 60 ml/min/1.73 m 2 had an ICD-9 diagnosis of CKD [15]. Another study at an academic heath-care center found recognition rates of 38 and 87% for stage 3 and 4, respectively [16]. The consistent finding in all these data is that physician recognition of mild to moderate kidney disease is suboptimal.…”

Interventions to Reduce Late Referrals to Nephrologists

“…As these studies illustrate, eGFR reporting alone without educational interventions appears to be insufficient in changing provider practice behavior [55,56]. Furthermore, rates of predialysis nephrology care in recent US studies do not appear to have changed, as up to one-third of patients with severe CKD (eGFR <30 ml/min/1.73 m 2 ) still do not receive a nephrology referral and a similar proportion of incident ESKD patients never received pre-ESKD nephrology care [16,57]. …”

eGFR

“…Multiple lines of evidence indicate that clinicians infer GFR from serum creatinine rather poorly (13,14). This is not surprising because the relation is not linear and the rates of creatinine production vary widely.…”