Evaluation and Treatment of CKD Patients Before and at Their First Nephrologist Encounter in Canada

Background: Much of the comorbidity associated with chronic kidney disease (CKD) begins in the early stages. Interventions with proven efficacy exist to decrease progression, morbidity, and mortality. This study examines their use in patients with CKD before and at their first nephrologist encounter in Canada.

Study Design: Prospective multicenter cohort study.

Setting & Participants: 482 patients at their first nephrologist encounter enrolled from 13 Canadian centers. Inclusion criteria were measured or estimated glomerular filtration rate less than 50 mL/min/1.73 m(2). Exclusion criteria were patients with acute kidney failure or those likely to require dialysis therapy within 3 months of referral.

Outcomes & Measurements: Describe: (1) characteristics of patients at their first nephrology encounter in Canada; (2) the evaluation for cardiac risk factors, cardiac diseases and CKD complications and their management before the encounter; (3) changes in management initiated by nephrologists at the first encounter; and (4) the availability and use of allied health professional services for CKD care.

Results: Patients had a mean age of 69.7 years, estimated glomerular filtration rate of 29 mL/min/1.73 m(2) (0.48 mL/s/1.73 m(2), hemoglobin level of 12.1 g/dL (121 g/L), albumin level of 3.6 g/dL (36 g/L), and blood pressure of 147/76 mm Hg. Transmission of results from prior evaluation was variable. At the encounter, nephrologists had available or ordered albumin and calcium/phosphate tests in greater than 70% of patients. Nephrologists did not evaluate parathyroid hormone in 83% of patients, lipids in greater than 50%, iron studies (in those with anemia) in 57%, and urine studies in 30%. Despite a high prevalence of diabetes and coronary artery disease, only 46% were administered medications to interrupt the renin-angiotensin system, 37% were administered acetylsalicylic acid, and 32% were administered lipid medication after the encounter. Availability and use of allied health professional resources varied and was low in an unstructured setting.

Limitations: External validity, referral bias, and inability to make causal inferences.

Conclusions: In Canada, patients with CKD continue to be encountered late by nephrologists (stage IV CKD). Information for prior evaluation is incompletely transmitted. Finally, there appears to be room for improvement in evaluation and treatment at the first nephrologist encounter.