Two Easy Steps Improve CKD Care

Jeffrey S. Berns, MD


May 05, 2014

Editorial Collaboration

Medscape &

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Hello. This is Jeffrey Berns, Editor-in-Chief of Medscape Nephrology. I want to bring to your attention 2 recently published articles that show how easy it can be to have a significant impact on some of our patients with chronic kidney disease (CKD). The first, which was recently published in the Journal of the American Society of Nephrology, is a randomized controlled trial of adding a nurse practitioner to usual care for patients with CKD.[1] This was done in The Netherlands. The patient population had moderate to severe CKD with estimated glomerular filtration rates (GFRs) of 20-70 mL/min/1.73 m2. The mean was about 35 mL/min/1.73 m2. Again, the patients were randomly assigned to either usual physician care or physician care with a nurse practitioner. The role of the nurse practitioner was to educate patients about lifestyle intervention, work with them with their medications and to improve medication adherence, and to educate them about CKD.

The findings were quite interesting and dramatic. The primary endpoint that was looked at after a median follow-up of over 5.5 years was a composite of death, end-stage renal disease, and a 50% increase in the serum creatinine. The intervention group (ie, the group with the nurse practitioners) had better measures overall of blood pressure control, proteinuria, LDL cholesterol, and use of certain medications such as aspirin, statins, and activated vitamin D. What was pretty remarkable was that there was about a 20% reduction in the composite endpoint at the end of follow-up. Interesting, also, is that the decline in GFR was statistically significantly lower by about 0.5 mL/min/1.73 m2/year in the nurse practitioner intervention group.

The benefit of this was not seen until about 2.5-3 years, so it takes some time to optimize the effect of having such a care model involved in managing CKD patients, which makes sense. Overall, if you look at the follow-up at 2 years or longer, there was a 63% reduction in end-stage renal disease and a 38% reduction in 50% increase in serum creatinine. So there was very significant improvement in important patient outcomes when physicians included nurse practitioners in the care of their CKD patients.

The other interesting paper was published recently in Kidney International by Kurella Tamura and colleagues.[2] It is a report of the National Kidney Foundation's screening and education program, Kidney Early Evaluation Program (KEEP). As you probably know, this is a community-based program. In this particular paper, they looked at about 600 patients who were screened by KEEP. They compared them with propensity-matched patients who had end-stage renal disease but were not screened through the KEEP program. This study ran from 2005 to 2010. They looked at what happens when the patients who were identified through the KEEP program had some education about CKD. The patients were identified by serum creatinine and urine albumin-to-creatinine ratio. Then the patients who had CKD were educated briefly about CKD risk factors, cardiovascular disease, and risk modification and were sent a care plan and some information about modifying risk factors for CKD and cardiovascular disease.

The authors found that the individuals who were screened through the KEEP program were more likely to have pre-end-stage renal disease care by a nephrologist. More went on peritoneal dialysis than hemodialysis: 10.3% vs 6.4%. More were on a transplant list before starting dialysis. More were transplanted at the end of follow-up vs those who were not identified through the KEEP program. Interestingly, there was a 20% reduction in mortality. No differences were seen in the likelihood of having an arteriovenous fistula or graft compared with a tunneled dialysis catheter. Nonetheless, some very substantial and important outcome benefits are associated with community-based screening and education of patients identified as having CKD.

I think we should work together as a renal community to get patients identified who have significant CKD and work very hard to educate them about CKD, cardiovascular disease, transplantation, and dialysis modalities. We can see from these 2 studies that without much expense or side effects -- these are pretty risk-free interventions -- we can have a substantial and very important impact on our patients. Thanks for listening. This is Jeffrey Berns, Editor-in-Chief of Medscape Nephrology, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.


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