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Outpatient nephrologic care resulted in fewer deaths in patients with diabetes, CKD
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Greater consistency of outpatient nephrologic care was associated with decreased mortality in patients with diabetes and stage-3 or stage-4 chronic kidney disease, according to new data.
However, these findings are troublesome, according to the researchers, because only a minority of patients received nephrologic care during the dialysis-free phase.
The researchers examined the frequency and consistency of outpatient nephrologic care in 39,031 patients. They calculated the number of visits to a nephrologist during a mean follow-up of 19.3 months. The majority of patients had early stage-3 chronic kidney disease (70%), followed by late stage-3 (22.4%) and stage-4 (7.6%).
More than one-quarter (28.2%) of patients with stage-4 chronic kidney disease visited a nephrologist. The numbers were lower for patients with early stage-3 (3.1%) and late stage-3 chronic kidney disease (9.5%).
Those patients with more visits to the nephrologist tended to have a lower mortality rate — 9.6 per 100 person-years for patients with early stage-3 chronic kidney disease; 14.1 per 100 person-years for patients with late stage-3 chronic kidney disease; and 19.4 per 100 person-years for patients with stage-4 chronic kidney disease.
“The results of our study support the National Kidney Foundation K/DOQI guideline to initiate comanagement with a nephrologist in patients with stage-3 chronic kidney disease and to refer patients to a nephrologist at the onset of stage-4 chronic kidney disease. However, only 6.4% of all patients visited a nephrologist during the baseline period compared with only a minority (28.2%) of all patients with stage-4 chronic kidney disease,” the researchers wrote. – by Katie Kalvaitis
Arch Int Med. 2008;168:55-62.
This recent publication by Tseng et al provides important observations regarding the beneficial impact of nephrology subspecialty care for patients with significant diabetic kidney disease. As you may know, diabetic kidney disease remains the leading cause of kidney failure in the United States. The U.S. Renal Data System Annual Report for 2007 shows that in 2005, 47,000 of the nearly 107,000 patients that began dialysis therapy had diabetic kidney disease. In addition, nearly 179,000 of the 485,000 patients already on dialysis in 2005 were diabetic. The current publication reviewed data on diabetic patients with significant kidney disease from the VA Health system in the United States from 1997 to 2000, and revealed that regular care by a nephrologist was associated with a lower risk for death than that seen for patients without regular nephrology health visits. This study is consistent with previous studies showing that early referral to a nephrologist is beneficial to patients with severe kidney disease who develop kidney failure. The study findings also suggested that only a small number of people with diabetes with significant kidney disease were being referred to nephrology subspecialty care in 1997 to 2000.
These data are important for clinical practice, as they emphasize the need for early nephrology referral for diabetic patients that develop significant kidney disease. Nephrologists are physicians that are specifically trained to address the multiple medical complications (anemia, high blood pressure, metabolic disturbances, problems with nutrition) associated with progressive loss of kidney function. As kidney disease progresses, patients typically require multiple medications to control such complications and their management requires experienced attention. It should be noted that in 2002, after the time period reported in this paper, the National Kidney Foundation Disease Outcomes Quality Initiative (K/DOQI) recommended that all patients with severe kidney disease be referred to a nephrologist to prepare them for dialysis therapy, and further that a nephrologist should be consulted for patients with moderate to significant kidney disease to assist with medical management of complications.
– Catherine M. Meyers, MD
Director of Inflammatory Renal Disease Program, NIH/NIDD