Improving the Detection of Chronic Kidney Disease Ayub Akbari, Heather D Clark, Peter J Swedko, Pete

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Improving the Detection of Chronic Kidney
DiseaseAyub Akbari, Heather D Clark, Peter J
Swedko, Peter O Magner, Daylily Ooi, Lisa J
Moore, William E Hogg Jacques Lemelin

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ESRD is Increasing
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(No Transcript)
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Cost to Health Care

• In 1999 about 2 billion was spent in Canada on
  caring for patients with ESRD.

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How can we delay progression to ESRD and Improve
care?

• Management of Hypertension
• Use of ACE inhibitors and ARBS
• Management of Anemia
• Management of electrolyte imbalance
• Management of malnutrition

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Early Detection of Kidney Disease is the KEY
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Serum Creatinine is NOT GFR!
GFR ml/min
Creatinine Clearance ml/min
Serum Creatinine umol/L
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Determinants of Serum Creatinine
Muscle mass Rate of turnover
Serum Creatinine
Filtration Tubular Secretion
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The Solution

• GFR should be calculated from prediction
  equations and reported directly to the physician
  with a multi faceted educational intervention

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Intervention

• Laboratory reporting of GFR
• Automatic reporting of the CG GFR by the Ottawa
  Hospital laboratory whenever the primary care
  physician requested a serum creatinine test
• On-site phlebotomist at the family practice
  clinic submitted patients weight on the lab
  requisition whenever serum creatinine was ordered

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Methods

• Subjects
• all patients in an academic family practice
  associated with the Ottawa Hospital who
• were aged 65 or greater (elderly)
• could have a Cockcroft-Gault GFR (CG GFR)
  calculated from their medical record between
  August 1997 and August 2000

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Methods (2)

• Exclusion Criteria
• they were undergoing dialysis
• they did not return for a follow-up appointment
  with their physician during the intervention
  period
• their CG GFR was less than 0.5 ml/sec
• we deemed it unethical not to inform the primary
  care physicians of these patients severely
  impaired kidney function

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Methods (3)

• Primary outcome
• Detection of CKD (CG GFR lt 1.3 ml/sec) by the
  family physician, both before and after the
  intervention
• Detection of CKD was defined as any evidence in
  the medical record that the physician had
  recognized impaired kidney function

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Results

• 700 patients aged ? 65 in whom CG GFR could be
  calculated
• Excluded
• 39 with CG GFR lt 0.5 ml/sec
• 322 had no CG GFR at OH lab
• 15 did not see their physician in follow-up after
  the CG GFR

N 324
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Table 1 Characteristics of Study Patients
CG GFR Cockcroft-Gault calculated glomerular
filtration rate. Values are means ? standard
deviation
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Figure 1 Detection Rate of Chronic Kidney Disease
Relative Increase 496.4
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Pre-Intervention
Post-Intervention
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Women Have Lower Serum Creatinine
Even Though Their CrCl is the Same as Men
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Conclusions

• Laboratory reporting of estimated GFR, along with
  an educational intervention, resulted in a
  dramatic increase in the detection of CKD by
  primary care physicians.
• The use of laboratory-reported GFR can eliminate
  bias towards the detection of CKD in men and
  diabetics.

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Limitations

• Before and after study (not randomized)
• Single centre
• Tertiary care centre
• Residents
• Very intensive educational intervention
• GFR lt 30 ml/min excluded
• Only elderly studied

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Next Steps

• Randomized controlled trial
• Intervention at community level
• Include patients with severe CKD
• Measure impact on nephrology services
• Does early detection matter for mild renal
  failure?