Trends in nephrology referral patterns for patients with chronic kidney disease: Retrospective cohort study

Ghimire, Anukul; Ye, Feng; Hemmelgarn, Brenda R.; Zaidi, Deenaz; Jindal, Kailash; Cooper, Matthew; James, Matthew T.; Khan, Maryam; Tinwala, Mohammed M; Sultana, Nayma; Ronksley, Paul E.; Muneer, Shezel; Klarenbach, Scott; Okpechi, Ikechi G.; Bello, Aminu K.

doi:10.1371/journal.pone.0272689

Cited by 5 publications

(3 citation statements)

References 46 publications

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“…Agents like these should be started early in treatment due to their cardio-and reno-protective properties. CKD G4-5 patients should be followed by a nephrologist to establish preventive treatments, especially prior to AMI [37]. Unfortunately, referral rates for these patients are low [38].…”

Section: Discussionmentioning

confidence: 99%

Rate and Risk Factors of Acute Myocardial Infarction after Debut of Chronic Kidney Disease—Results from the KidDiCo

Kampmann

Heaf

Mogensen

et al. 2022

JCDD

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Chronic kidney disease (CKD) is a known risk factor for cardiovascular disease, including acute myocardial infarction. However, whether this risk is only associated with severe kidney disease or is also related to mildly impaired kidney function is still under debate. The incidence rate and risk factors of incident acute myocardial infarction (AMI) in patients with CKD are sparse. Potential differences in risk factor profiles between CKD patients with incident AMI and CKD patients with a prior AMI have not been sufficiently investigated. Furthermore, important factors such as albuminuria and socio-economic factors are often not included. The primary aim of this study was to establish the incidence rate of AMI after CKD debut. Secondly, to evaluate the importance of different CKD stages and the risk of having an AMI. Finally, to identify individuals at risk for AMI after CKD debut adjusted for prevalent AMI. Based on data from the kidney disease cohort of Southern Denmark (KidDiCo), including 66,486 CKD patients, we established incidence rates and characteristics of incident AMI among patients within a 5-year follow-up period after CKD debut. A Cox regression was performed to compute the cause-specific hazard ratios for the different risk factors. The incidence rate for CKD stage G3–5 patients suffering acute myocardial infarction is 2.5 cases/1000 people/year. In patients without a previous myocardial infarction, the risk of suffering a myocardial infarction after CKD debut was only significant in CKD stage G4 (HR = 1.402; (95% CI: 1.08–1.81); p-value = 0.010) and stage G5 (HR = 1.491; (95% CI: 1.01–2.19); p-value = 0.042). This was not the case in patients who had suffered an acute myocardial infarction prior to their CKD debut. In this group, a previous myocardial infarction was the most critical risk factor for an additional myocardial infarction after CKD debut (HR = 2.615; (95% CI: 2.241–3.05); p-value < 0.001). Irrespective of a previous myocardial infarction, age, male sex, hypertension, and a low educational level were significant risk factors associated with an acute myocardial infarction after CKD debut. The incidence rate of AMI in patients with CKD stage G3–5 was 2.5 cases/1000 people/year. Risk factors associated with incident AMI in CKD stage G3–5 patients were CKD stage, age, and hypertension. Female sex and higher educational levels were associated with a lower risk for AMI. Prior AMI was the most significant risk factor in patients with and without previous AMI before fulfilling CKD stage G3–5 criteria. Only age, sex, and a medium-long educational level were significant risk factors in this group.

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Section: Discussionmentioning

confidence: 99%

Rate and Risk Factors of Acute Myocardial Infarction after Debut of Chronic Kidney Disease—Results from the KidDiCo

Kampmann

Heaf

Mogensen

et al. 2022

JCDD

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“…2 However, most interventions to prevent progression of CKD have the strongest evidence for efficacy when initiated at higher eGFR, [3][4][5] and primary care physicians frequently refer patients to nephrologists at early stages of CKD. 6 As there are more patients with early stages of CKD than can be cared for by nephrologists, 7 other models of providing evidence-based care for people with early CKD are needed.…”

Section: Introductionmentioning

confidence: 99%

Nurse Practitioner Care Compared with Primary Care or Nephrologist Care in Early CKD

James,

Scory,

Novak

et al. 2023

CJASN

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Background: Early interventions in chronic kidney disease (CKD) have been shown to improve health outcomes; however, gaps in access to nephrology care remain common. Nurse practitioners can improve access to care; however, the quality and outcomes of nurse practitioner care for CKD are uncertain. Methods: In this propensity score matched cohort study, patients with CKD meeting criteria for nurse practitioner care were matched 1:1 on their propensity scores for; 1) nurse practitioner care versus primary care alone, as well as 2) nurse practitioner versus nephrologist care. Processes of care were measured within one year following cohort entry, and clinical outcomes were measured over 5 years of follow-up and compared between propensity score matched groups. Results: 961 (99%) patients from the nurse practitioner clinic were matched on their propensity score to 961 (1%) patients receiving primary care only, while 969 (100%) patients from the nurse practitioner clinic were matched to 969 (7%) patients receiving nephrologist care. After matching to patients receiving primary care alone, those receiving nurse practitioner care had greater use of ACEi/ARB (82 versus 79%, absolute differences [AD] 3.4 [95% CI 0.0, 6.9]%) and statins (75 versus 66%, AD 9.7 [5.8, 13.6]%), fewer prescriptions of NSAIDS (10 versus 17%, AD –7.2 [-10.4, -4.2]%), greater eGFR and albuminuria monitoring, and lower rates of all-cause hospitalization (34.1 versus 43.3, rate difference -9.2 [-14.7, -3.8] per 100 person-years) and all-cause mortality (3.3 versus 6.0, rate difference -2.7 [-3.6, -1.7] per 100 person-years). When matched to patients receiving nephrologist care, those receiving nurse practitioner care were also more likely to be prescribed ACEi/ARBs and statins, with no difference in the risks of experiencing adverse clinical outcomes. Conclusions: Nurse practitioner care for patients with CKD was associated with better guideline-concordant care than primary care alone or nephrologist care, with clinical outcomes that were better than or equivalent to primary care alone, and similar to those with care by nephrologists.

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“…The recurrence of late referrals varies significantly across the globe. On average, 20-35% of CKD patients are referred late to the nephrologist (Ghimire et al, 2022). In Pakistan, the ratio of late referrals is comparatively low than developing countries such as the UK (30%), Denmark (38%), Mexico (50%) and the USA (34.7%) (Anees et al, 2018).…”

Section: Introductionmentioning

confidence: 99%

Factors Impacting the Referral Time to Nephrologists in Chronic Kidney Disease Patients in South Punjab, Pakistan

KHALID

SAEED

JAUHAR

et al. 2022

Biol Clin Sci Res J

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To assess the social, demographic, clinical and health factors impacting the referral time to a nephrologist in chronic kidney disease patients. A prospective study was carried out at Nephrology Department of Nishtar Medical Hospital, Multan from October 2021-October 2022. A total of 150 chronic kidney disease patients who were undergoing dialysis were selected for the study. Early and late referral time was evaluated by the time period between referral and dialysis initiation. All the patients were interviewed for evaluation of factors affecting the referral time. The analysis showed that 92 patients (61.3%) were in early referral and 58 patients (38.6%) were in late referral among which 21 patients were referred to a nephrologist almost 90 days prior to the dialysis initiation. Patients in the late referral mostly had diabetes, congestive heart failure or hypertension, whereas patients in early referral were non-smokers, women and patients with glomerulonephritis. The multivariate analysis revealed the following independent risk factors for late referral: kidney disease (diabetes mellitus: OR 1.499, 95% CI 1.049–2.142, hypertension OR 1.989, 95% CI 1.299–3.048), male sex (OR: 1.455, 95% CI: 1.029–2.069), congestive heart failure (OR 2.137, 95% CI 1.537–2.997), profession (labourer OR 3.199, 95% CI 1.398–7.320, mechanic OR 2.969, 95% CI 1.439–6.119, farmer OR 5.139, 95% CI 2.210–11.938) and assisted walks (OR 2.066, 95% CI 1.377–3.107). Diabetes and hypertension patients have a later referral time than patients with glomerulonephritis. In addition, men with congestive heart failure practicing physically active professions and assisted ambulation were referred late.

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Trends in nephrology referral patterns for patients with chronic kidney disease: Retrospective cohort study

Cited by 5 publications

References 46 publications

Rate and Risk Factors of Acute Myocardial Infarction after Debut of Chronic Kidney Disease—Results from the KidDiCo

Rate and Risk Factors of Acute Myocardial Infarction after Debut of Chronic Kidney Disease—Results from the KidDiCo

Nurse Practitioner Care Compared with Primary Care or Nephrologist Care in Early CKD

Factors Impacting the Referral Time to Nephrologists in Chronic Kidney Disease Patients in South Punjab, Pakistan

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