Nearly half of patients with high-risk CKD do not have a nephrology visit within 1 year
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Among patients with a high risk for chronic kidney disease progression, less than half attend a nephrology visit within 1 year of established risk, according to a recently published study.
“The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines and several other clinical guidelines recommend nephrology referrals based on laboratory tests, including serum creatinine and urine albumin-to-creatinine ratio (ACR). However, strict adherence to the KDIGO referral recommendations may be infeasible when they would likely result in referrals far outnumbering the supply of nephrology care at a tertiary care center,” Maggie Wang, BS, from the department of biomedical data science in the school of medicine at Stanford University in California, and colleagues wrote. They added, “Our objective was to examine the gap in nephrology care between patients with CKD at predictably high risk for kidney failure and those receiving treatment from a nephrologist. We analyzed rates of nephrology visits across the Kidney Failure Risk Equation (KFRE) risk levels in a large U.S. national cohort, focusing on patients not yet receiving nephrology care at the time when their risk became identifiable by the KFRE.”
In a population-based, retrospective cohort study, researchers evaluated nationwide administrative health claims data from 156,733 adults with CKD (mean age was 74.6 years; 58.6% were women; 55.2% were white) between Jan. 1, 2012, and Dec. 31, 2019. All patients had an available urine albumin-to-creatinine ratio within 90 days of a serum laboratory test.
Researchers calculated the kidney failure risk of each patient with the 5-year KRFE and considered nephrology care rates across tiers of risk to be the main outcome. Within each risk group, researchers measured the nephrology visit rate as the proportion of patients with a visit to a nephrologist in the 1-year period after their index time. Analyses were repeated in subgroups by race and ethnicity, sex, index year and age.
Overall, 67.6% of patients had a low 5-year risk of kidney failure. Among the 137 highest-risk patients, 57.7% had a nephrology visit. A total of 7,730 patients had a risk above a 10% threshold and 41.5% of them had a nephrology visit. Researchers observed the nephrology visit rates increased with higher kidney failure risk.
“Our results offer insight into the opportunity for health care systems to identify and target a considerable proportion of patients with CKD who are not receiving nephrology care despite demonstrably elevated kidney risk and may help to inform future clinical and policy decisions aimed at bridging this gap,” Wang and colleagues wrote. They added, “Of interest, the gap in nephrology care was more pronounced in incident than in prevalent nephrology care, which suggests that patients at high risk who have not previously been seen by a nephrologist are systematically more likely to continue to not be seen. Future work could examine whether embedded risk prediction and automatic referrals might help bring appropriate nephrology care to previously unreferred and unseen high-risk patients.”
Researchers noted that potential factors in the gap could include under referral and lack of follow-through in patients who had a referral placed. Additionally, a shortage of nephrologists may contribute to the problem.
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