Recognition and Management of Chronic Kidney Disease in an Elderly Ambulatory Population

  • Michael B. Rothberg
  • Eileen D. Kehoe
  • Abbie L. Courtemanche
  • Thabo Kenosi
  • Penelope S. Pekow
  • Maura J. Brennan
  • Jeffrey G. Mulhern
  • Gregory L. Braden
Original Article

Abstract

Background

Chronic kidney disease (CKD) is a growing problem among the elderly. Early detection is considered essential to ensure proper treatment and to avoid drug toxicity, but detection is challenging because elderly patients with CKD often have normal serum creatinine levels. We hypothesized that most cases of CKD in the elderly would go undetected, resulting in inappropriate prescribing.

Objective

To determine whether recognition of CKD is associated with more appropriate treatment

Design

Retrospective chart review

Participants

All patients aged ≥65 years with a measured serum creatinine in the past 3 years at 2 inner city academic health centers.

Measurements

Estimated glomerular filtration rate (eGFR) calculated using the Modified Diet in Renal Disease equation, and for patients with eGFR < 60, documentation of CKD by the provider, diagnostic testing, nephrology referral and prescription of appropriate or contraindicated medications.

Results

Of 814 patients with sufficient information to estimate eGFR, 192 (33%) had moderate (eGFR < 60 mL/min) and 5% had severe (eGFR < 30 mL/min) CKD. Providers identified 38% of moderate and 87% of severe CKD. Compared to patients without recognized CKD, recognized patients were more likely to receive an ACE/ARB (80% vs 61%, p = .001), a nephrology referral (58% vs 2%, p < .0001), or urine testing (75% vs 47%, p < .0001), and less likely to receive contraindicated medications (26% vs 40%, p = .013).

Conclusions

Physicians frequently fail to diagnose CKD in the elderly, leading to inappropriate treatment. Efforts should focus on helping physicians better identify patients with low GFR.

KEY WORDS

chronic kidney disease diagnosis creatinine ace inhibitors elderly 

References

  1. 1.
    Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139:137–47.PubMedGoogle Scholar
  2. 2.
    Clase CM, Garg AX, Kiberd BA. Prevalence of low glomerular filtration rate in nondiabetic Americans: Third National Health and Nutrition Examination Survey (NHANES III). J Am Soc Nephrol. 2002;13:1338–49.PubMedCrossRefGoogle Scholar
  3. 3.
    Maschio G, Alberti D, Janin G, et al. Effect of the angiotensin-converting-enzyme inhibitor benazepril on the progression of chronic renal insufficiency. The Angiotensin-Converting-Enzyme Inhibition in Progressive Renal Insufficiency Study Group. N Engl J Med. 1996;334:939–45.PubMedCrossRefGoogle Scholar
  4. 4.
    The GISEN Group (Gruppo Italiano di Studi Epidemiologici in Nefrologia). Randomised placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of terminal renal failure in proteinuric, non-diabetic nephropathy. Lancet. 1997;349:1857–63.CrossRefGoogle Scholar
  5. 5.
    Jafar TH, Stark PC, Schmid CH, et al. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med. 2003;139:244–52.PubMedGoogle Scholar
  6. 6.
    Papaioannou A, Ray JG, Ferko NC, Clarke JA, Campbell G, Adachi JD. Estimation of creatinine clearance in elderly persons in long-term care facilities. Am J Med. 2001;111:569–73.PubMedCrossRefGoogle Scholar
  7. 7.
    National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002;39:S1–266.Google Scholar
  8. 8.
    Mathew TH. Chronic kidney disease and automatic reporting of estimated glomerular filtration rate: a position statement. Med J Aust. 2005;183:138–41.PubMedGoogle Scholar
  9. 9.
    Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31–41.PubMedCrossRefGoogle Scholar
  10. 10.
    Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999;130:461–70.PubMedGoogle Scholar
  11. 11.
    Garg AX, Papaioannou A, Ferko N, Campbell G, Clarke JA, Ray JG. Estimating the prevalence of renal insufficiency in seniors requiring long-term care. Kidney Int. 2004;65:649–53.PubMedCrossRefGoogle Scholar
  12. 12.
    Verhave JC, Fesler P, Ribstein J, du Cailar G, Mimran A. Estimation of renal function in subjects with normal serum creatinine levels: influence of age and body mass index. Am J Kidney Dis. 2005;46:233–41.PubMedCrossRefGoogle Scholar
  13. 13.
    Van Den Noortgate NJ, Janssens WH, Delanghe JR, Afschrift MB, Lameire NH. Serum cystatin C concentration compared with other markers of glomerular filtration rate in the old old. J Am Geriatr Soc. 2002;50:1278–82.CrossRefGoogle Scholar
  14. 14.
    Cirillo M, Anastasio P, De Santo NG. Relationship of gender, age, and body mass index to errors in predicted kidney function. Nephrol Dial Transplant. 2005;20:1791–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Fehrman-Ekholm I, Skeppholm L. Renal function in the elderly (>70 years old) measured by means of iohexol clearance, serum creatinine, serum urea and estimated clearance. Scand J Urol Nephrol. 2004;38:73–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Swedko PJ, Clark HD, Paramsothy K, Akbari A. Serum creatinine is an inadequate screening test for renal failure in elderly patients. Arch Intern Med. 2003;163:356–60.PubMedCrossRefGoogle Scholar
  17. 17.
    Wyatt C, Konduri V, Eng J, Rohatgi R. Reporting of estimated GFR in the primary care clinic. Am J Kidney Dis. 2007;49:634–41.PubMedCrossRefGoogle Scholar
  18. 18.
    Akbari A, Swedko PJ, Clark HD, et al. Detection of chronic kidney disease with laboratory reporting of estimated glomerular filtration rate and an educational program. Arch Intern Med. 2004;164:1788–92.PubMedCrossRefGoogle Scholar
  19. 19.
    Quartarolo JM, Thoelke M, Schafers SJ. Reporting of estimated glomerular filtration rate: effect on physician recognition of chronic kidney disease and prescribing practices for elderly hospitalized patients. J Hosp Med. 2007;2:74–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Mackinnon NJ, Helper CD. Indicators of preventable drug-related morbidity in older adults 2. Use within a managed care organization. J Manag Care Pharm. 2003;9:134–41.PubMedGoogle Scholar
  21. 21.
    Curtis LH, Ostbye T, Sendersky V, et al. Inappropriate prescribing for elderly Americans in a large outpatient population. Arch Intern Med. 2004;164:1621–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Higashi T, Shekelle PG, Solomon DH, et al. The quality of pharmacologic care for vulnerable older patients. Ann Intern Med. 2004;140:714–20.PubMedGoogle Scholar
  23. 23.
    Hostetter TH, Lising M. National kidney disease education program. J Am Soc Nephrol. 2003;14:S114–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Levey AS, Coresh J, Greene T, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006;145:247–54.PubMedGoogle Scholar
  25. 25.
    Winkelmayer WC, Owen WF Jr., Levin R, Avorn J. A propensity analysis of late versus early nephrologist referral and mortality on dialysis. J Am Soc Nephrol. 2003;14:486–92.PubMedCrossRefGoogle Scholar
  26. 26.
    Jones C, Roderick P, Harris S, Rogerson M. Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease. Nephrol Dial Transplant. 2006;21:2133–43.PubMedCrossRefGoogle Scholar
  27. 27.
    Fox CH, Brooks A, Zayas LE, McClellan W, Murray B. Primary care physicians’ knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) Study. J Am Board Fam Med. 2006;19:54–61.PubMedGoogle Scholar
  28. 28.
    Lea JP, McClellan WM, Melcher C, Gladstone E, Hostetter T. CKD risk factors reported by primary care physicians: do guidelines make a difference? Am J Kidney Dis. 2006;47:72–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Boulware LE, Troll MU, Jaar BG, Myers DI, Powe NR. Identification and referral of patients with progressive CKD: a national study. Am J Kidney Dis. 2006;48:192–204.PubMedCrossRefGoogle Scholar
  30. 30.
    Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351:1296–305.PubMedCrossRefGoogle Scholar
  31. 31.
    Health Care Financing Administration. Network of New England I. End Stage Renal Disease 1999 Annual Report. New Haven, CT; 1999:84.Google Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Michael B. Rothberg
    • 1
    • 3
  • Eileen D. Kehoe
    • 2
    • 3
  • Abbie L. Courtemanche
    • 1
    • 3
  • Thabo Kenosi
    • 1
    • 3
  • Penelope S. Pekow
    • 4
  • Maura J. Brennan
    • 1
    • 3
  • Jeffrey G. Mulhern
    • 2
    • 3
  • Gregory L. Braden
    • 2
    • 3
  1. 1.Division of General Medicine and GeriatricsBaystate Medical CenterSpringfieldUSA
  2. 2.Division of Nephrology, Department of MedicineBaystate Medical CenterSpringfieldUSA
  3. 3.Tufts University School of MedicineBostonUSA
  4. 4.The School of Public HealthUniversity of MassachusettsAmherstUSA

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