Natural history of CKD stage 4 and 5 patients following referral to renal management clinic
- 283 Downloads
CKD patients referred to a renal management clinic are looked after by a multidisciplinary team whose care may improve outcome and delay the progression of kidney disease. This paper describes our experience and the results obtained in 940 patients with CKD stage 4 and 5 patients from two renal management clinics (RMC).
Subjects and methods
We collected and analyzed the data from 940 patients with CKD stage 4 and 5 at the RMCs of the Toronto General Hospital (TGH), University Health Network and The Scarborough General Hospital (TSH) from January 2000 to November 2007. Inclusion criteria for the study required at least three measurements of serum creatinine over a minimum follow-up of 6 months. We calculated the change of slope of the estimated GFR by linear regression analysis. The slopes were further subdivided into five groups: improved eGFR (eGFR slope ≥+5 ml/min/year); mild improvement (slope >+1 to <+5 ml/min/year); stable (slope <+1 to >−1 ml/min/year); slow progression (i.e., deterioration; slope <−1 to >−5 ml/min/year) and rapid progression (slope >−5 ml/min/year).
During a median follow-up of 1.57 year (range 0.5–8.7 year) of stage 4 patients, eGFR improved in 10.6%, showed mild improvement in 24.2%, was stable in 27.5%, showed slow progression in 28.8% and rapid progression in 8.9% of patients. During a median follow-up of 1.4 year (range 0.5–8 year) of CKD stage 5 patients, eGFR improved in only 1.3%, showed mild improvement in 4.3%, remained stable in 35.6%; showed slow progression in 19.7% and rapid progression in 39.1%. Between the two hospitals (TGH and TSH) there was a statistically significant difference in the number of visits per year for CKD stage 4 patients during the first, second and third year. However, the number of visits per year had no effect on the rate of decline. On univariate analysis, factors predicting non-progression in eGFR slope were eGFR at referral, the use of ACE inhibitors-ARBs and absence of cardiovascular disease. However, in logistic multivariate regression analysis, after adjusting for confounding factors only the eGFR at referral and ACE inhibitors-ARBs were independent factors for non-progression in eGFR.
Summary and conclusions
A significant percentage of CKD stage 4 patients attending a renal management clinic (RMC) showed non-progression or improvement in their kidney function. Although only few stage 5 CKD patients had improvement in their eGFR, 32% of them maintained their eGFR on conservative treatment for over 2 years delaying the initiation of dialysis.
KeywordsCourse analysis Chronic kidney disease eGFR Renal management clinic
- 4.United States Renal Data System (USRDS) (2003) USRDS annual report: incidence and prevalence of ESRD. Am J Kid Dis 42(Suppl 5):1–230Google Scholar
- 5.K/DOQI clinical practice guidelines for chronic kidney disease (2002) Evaluation classification and stratification kidney disease outcomes quality initiative. Am J Kid Dis 39(Suppl 2):S7–S246Google Scholar
- 7.Van Biesen W, Vanholder R, Veys N, Verbeke F, Delanghe J, De Bacquer D et al (2006) The importance of standardization of creatinine in the implementation of guidelines and recommendations for CKD: implications for CKD management programmes. Nephrol Dial Transplant 21(1):77–83 Epub 2005 Oct 12CrossRefPubMedGoogle Scholar
- 13.Pohl MA, Blumenthal S, Cordonnier DJ, De Alvaro F, Deferrari G, Eisner G et al (2005) Independent and additive impact of blood pressure control and angiotensin II receptor blockade on renal outcomes in the Irbesartan diabetic nephropathy trial: clinical implications and limitations. J Am Soc Nephrol 16:3027–3037CrossRefPubMedGoogle Scholar
- 17.Tattersall J, Martin-Malo A, Pedrini L, Basci A, Canaud B, Fouque D et al (2007) EBPG guideline on dialysis strategies. Nephrol Dial Trans 22(2):5–21Google Scholar