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

Abstract

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.

Clinical Management of Chronic Kidney Disease Patients in Italy: Results from the IRIDE Study

“…Estimates from the Italian dialysis and transplant registry reported approximately 45,000-49,000 patients on dialysis from 2011 to 2013 [14]. In contrast, data related to the real-life clinical management and outcomes of stage 1 through 5 CKD patients not on dialysis is extremely limited, with few studies conducted in Italy [15,16]. The aim of IRIDE (Italian obseRvatIonal study on management of CKD patiEnts and related costs), a multicenter, prospective, observational study, was to describe the course of the disease and the clinical management of Italian patients with CKD over a 3-year period.…”

Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD

“…The consequences of CKD are severe, including progression to ESRD and premature development of cardiovascular diseases and death (2)(3)(4)(5)(6)(7). Although no randomized trials have been performed, .20 years of accumulating evidence has suggested that early nephrologist care is associated with slower CKD progression and lower rates of adverse outcomes (8)(9)(10)(11)(12)(13)(14)(15)(16). Despite practice guidelines recommending that patients in CKD stages 4-5 should be under nephrologist care (6,17), late nephrologist care is still common (18).…”

When kidneys get old: an essay on nephro-geriatrics

“…48 Two more recent studies among elderly individuals, one from Italy and the other from Sweden, independently demonstrated association of higher mortality with CKD category 3B but not 3A. 49,50 Taken together, we strongly believe that this analysis provides a powerful argument in favor of the need for an age-sensitive approach to diagnosing CKD based on GFR alone, perhaps using a threshold of < 45 ml/min/1.73m 2 rather than < 60 ml/min/1.73m 2 in those over 65 years of age.…”