Inconsistent lab reviews make CKD detection difficult
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PHOENIX – A lack of consistent laboratory testing of patients nationwide for markers of chronic kidney disease who have already been diagnosed and are receiving treatment for diabetes and hypertension undermines efforts to slow the progression of the disease, a speaker said here.
The National Kidney Foundation has been working with leading national laboratories and pathology societies to develop a kidney profile lab panel that can be used by primary care physicians to track CKD progression in high risk patients, the speaker noted.
“We know that over 90% of people with chronic kidney disease remain undiagnosed in the primary care population,” Elizabeth Montgomery, vice president of learning strategies and primary care programs for the NKF, told attendees at the Southwest Nephrology Conference.
A study recently published in PLOS One looked at 10,000 patients with type 2 diabetes in 466 primary care practices, Montgomery noted. In that group, 88% of people who had laboratory evidence of CKD at the time of the trial remained undetected in primary care.
“That included a significant percentage of people who had already advanced to stage 4 and 5 who remained undetected,” she said. “This is what we understand the national reality to be.”
Gail Guerrero-Tucker, MD, MPH, FAAFP, president of the Arizona Association of Family Physicians and part of the panel discussion on the kidney profile, told attendees that standing orders for primary care physicians would help.
“If we have more standardized orders to test for CKD, I think you fix many of these problems,” she said. There are also many challenges for patients who live in rural parts of Arizona, where sometimes helicopters are used to transport patients to dialysis.
U.S. Renal Data Systems information also confirms most people at risk – an estimated 60% of people with diabetes and with diabetes and/or hypertension and 94% of patients with hypertension alone – remain undetected for CKD in primary care, Montgomery said.
To address the issue, the NKF has been working with the American Medical Group Association (AMGA), a group that provides educational, advocacy and information services to large integrated health care networks with more than 200 members.
“AMGA has a relationship with Optimum (Health Care) and they have access to 32 million lives. They did an analysis for us and extracted information on people with diabetes aged 18 to 89 [years] … [and] they looked to see what percentage of these people were tested for albumin-creatine ratio,” a sign that kidney disease was present, along with eGFR. “When we went to AMGA, we wanted to see what percentage of people had been screen for both tests,” Montgomery said. “Guidelines from the NKF and the [American Diabetes Association] show that patients with a diagnosis of diabetes should be tested annual for albuminuria and eGFR.”
In this group of patients with diabetes, Montgomery said, they found the highest reported rate of patients receiving both tests was 61% “and there were some institutions that were less than 20%.”
The result of that research work, Montgomery said, was to develop a national laboratory engagement plan. As part of that effort, the NKF of Arizona helps connect Montgomery with Sonora Quest labs, one of largest in the state.
“We asked them to do some of their own research, and they found that over 80% of patients with a diagnosis of diabetes had not been tested for albuminuria or eGFR and in people who had evidence of CKD, 82% did not receive a test for albuminuria in the last 12 months,” Montgomery said.
“This is reflective of what the national data says about screening for CKD in primary care,” she added.
Guerrero-Tucker said primary care physicians want to find a middle ground that gets patients CKD care when they need it.
“As soon as we send patients off to specialists, we lose control over them,” she said. “There has to be a way to work together.” – by Mark E. Neumann
Reference:
Montgomery E. and Guerrero-Tucker G. The kidney profile and primary care: Guidelines for optimizing the detection and management of CKD in primary care. Presented at: the Southwest Nephrology Conference; March 6-7, 2020; Phoenix.
Disclosures: Montgomery and Tucker report no relevant financial disclosures.
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