Skip to main content

Advertisement

SpringerLink
Log in

General practitioners’ representation of early-stage CKD is a barrier to adequate management and patient empowerment: a phenomenological study

  • Original Article
  • Published:
Journal of Nephrology Aims and scope Submit manuscript

Abstract

Background

In high-income countries, chronic kidney disease (CKD) affects over 10% of the population. Identifying these patients early is a priority, especially as new treatments are available to reduce the risk of cardiovascular and renal morbidity. We aimed at understanding the management and care pathway of patients with early-to-moderate CKD defined as an estimated glomerular filtration rate (eGFR) ≥ 45 mL/min/1.73 m2 (CKD-EPI), by analyzing the experience of general practitioners in a region in France.

Methods

This qualitative semiopragmatic phenomenological study analyzed in-depth interviews held with a purposive sample (age, gender, training, type of practice, rural/urban context) of 24 general practitioners, with triangulation of research until data saturation.

Results

From diagnostic, etiological and prognostic viewpoints, the general practitioners enrolled in our study perceived CKD as a complex, poorly-defined clinical entity in asymptomatic and multimorbid patients. They distinguished it from a rare condition they considered as ‘mainly renal’. The fact that they did not perceive early-stage CKD as a disease was a hindrance to patient care, which should protect the kidneys with a preventive approach. Indeed, general practitioners perceived CKD patient management as a pathway requiring a personalized, integrative model, common to all chronic diseases, without necessarily involving a nephrologist, at least in the early stages.

Conclusions

This study shows how the general practitioners’ representations influence their attitudes and interventions. Clarifying the concept of early-stage CKD by taking factors like age and etiology into account would facilitate personalized management of this heterogeneous, often multimorbid, population. Finally, organizational models to support patient empowerment in an integrative care pathway must be established and validated.

Graphical abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Data availability

Data (French anonymous verbatim) are available upon request from the corresponding author.

References

  1. Elliott MJ, Gil S, Hemmelgarn BR et al (2017) A scoping review of adult chronic kidney disease clinical pathways for primary care. Nephrol Dial Transplant 32:838–846

    PubMed  Google Scholar 

  2. Couser WG, Remuzzi G, Mendis S, Tonelli M (2011) The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int 80:1258–1270

    Article  PubMed  Google Scholar 

  3. Matsushita K, Coresh J, Sang Y et al (2015) Kidney measures beyond traditional risk factors for cardiovascular prediction: a collaborative meta-analysis. Lancet Diabetes Endocrinol 3:514–525

    Article  PubMed  PubMed Central  Google Scholar 

  4. Meraz-Muñoz AY, Weinstein J, Wald R (2021) eGFR decline after SGLT2 inhibitor initiation: the tortoise and the hare reimagined. Kidney360 2:1042–1047

    Article  PubMed  PubMed Central  Google Scholar 

  5. Legrand K, Speyer E, Stengel B et al (2020) Perceived health and quality of life in patients with CKD, including those with kidney failure: findings from national surveys in France. Am J Kidney Dis 75:868–878

    Article  CAS  PubMed  Google Scholar 

  6. Shlipak MG, Tummalapalli SL, Boulware LE et al (2021) The case for early identification and intervention of chronic kidney disease: conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference. Kidney Int 99:34–47

    Article  PubMed  Google Scholar 

  7. Torreggiani M (2022) Referral of patients with chronic kidney disease: inconsistencies between guidelines and real-life practice, more questions than answers. J Nephrol 35:1371–1373

    Article  PubMed  PubMed Central  Google Scholar 

  8. Levin A, Stevens P, Bilous RW et al (2013) Kidney disease: Improving global outcomes (KDIGO) CKD work group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 3:1–150

    Google Scholar 

  9. Tonelli M, Dickinson JA (2020) Early detection of CKD: implications for low-income, middle-income, and high-income countries. J Am Soc Nephrol 31:1931–1940

    Article  PubMed  PubMed Central  Google Scholar 

  10. Tonelli M, Wiebe N, Manns BJ et al (2018) Comparison of the complexity of patients seen by different medical subspecialists in a universal health care system. JAMA Netw Open 1:e184852

    Article  PubMed  PubMed Central  Google Scholar 

  11. HAS 2021 Synthèse, MRC de l’adulte: les points critiques du parcours. Document de travail 23 juin 2021

  12. Weckmann GFC, Stracke S, Haase A et al (2018) Diagnosis and management of non-dialysis chronic kidney disease in ambulatory care: a systematic review of clinical practice guidelines. BMC Nephrol 19:258

    Article  PubMed  PubMed Central  Google Scholar 

  13. Llewellyn S (2019) The chronic care model, kidney disease, and primary care: a scoping review. Nephrol Nurs J 46:301–328

    PubMed  Google Scholar 

  14. Greer RC, Liu Y, Cavanaugh K et al (2019) Primary care physicians’ perceived barriers to nephrology referral and co-management of patients with CKD: a qualitative study. J Gen Intern Med 34:1228–1235

    Article  PubMed  PubMed Central  Google Scholar 

  15. Schulz C, Messikh Z, Reboul P et al (2022) Characteristics of outpatients referred for a first consultation with a nephrologist: impact of different guidelines. J Nephrol 35:1375–1385

    Article  PubMed  Google Scholar 

  16. van Dipten C, van Berkel S, van Gelder VA et al (2017) Adherence to chronic kidney disease guidelines in primary care patients is associated with comorbidity. Fam Pract 34:459–466

    Article  PubMed  Google Scholar 

  17. van Dipten C, van Berkel S, de Grauw WJC et al (2018) General practitioners’ perspectives on management of early-stage chronic kidney disease: a focus group study. BMC Fam Pract 19:81

    Article  PubMed  PubMed Central  Google Scholar 

  18. Sperati CJ, Soman S, Agrawal V et al (2019) Primary care physicians’ perceptions of barriers and facilitators to management of chronic kidney disease: a mixed methods study. PLoS ONE 14:e0221325

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Neale EP, Middleton J, Lambert K (2020) Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review. BMC Nephrol 21:83

    Article  PubMed  PubMed Central  Google Scholar 

  20. Fracso D, Bourrel G, Jorgensen C et al (2022) The chronic disease Self-Management Programme: a phenomenological study for empowering vulnerable patients with chronic diseases included in the EFFICHRONIC project. Health Expect 25:947–958

    Article  PubMed  PubMed Central  Google Scholar 

  21. Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 19:349–357

    Article  PubMed  Google Scholar 

  22. Palinkas LA, Horwitz SM, Green CA et al (2015) Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health 42:533–544

    Article  PubMed  PubMed Central  Google Scholar 

  23. Peirce CS (1935) Pragmatism and pragmaticism and scientific metaphysics. In: Weiss P (ed) Hartshorne C. Belknap Press: : An Imprint of Harvard University Press, Boston

    Google Scholar 

  24. Glaser BG, Strauss AL (1967) The discovery of grounded theory: strategies for qualitative research. Aldine Transaction, Chicago

    Google Scholar 

  25. Oliva-Damaso N, Delanaye P, Oliva-Damaso E et al (2022) Risk-based versus GFR threshold criteria for nephrology referral in chronic kidney disease. Clin Kidney J 15:1996–2005

    Article  PubMed  PubMed Central  Google Scholar 

  26. Tiu H, Fagerlin A, Roney M et al (2018) Provider perspectives on chronic kidney disease diagnosis delivery. Clin Nephrol 89:205–213

    Article  PubMed  Google Scholar 

  27. Chu CD, Powe NR, Shlipak MG et al (2022) Albuminuria testing and nephrology care among insured US adults with chronic kidney disease: a missed opportunity. BMC Prim Care 23:299

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. James G, Garcia Sanchez JJ, Carrero JJ et al (2022) Low adherence to kidney disease: improving global outcomes 2012 CKD clinical practice guidelines despite clear evidence of utility. Kidney Int Rep 7:2059–2070

    Article  PubMed  PubMed Central  Google Scholar 

  29. Weckmann G, Wirkner J, Kasbohm E et al (2022) Monitoring and management of chronic kidney disease in ambulatory care—nalysis of clinical and claims data from a population-based study. BMC Health Serv Res 22:1330

    Article  PubMed  PubMed Central  Google Scholar 

  30. Litvin CB, Nietert PJ, Jenkins RG et al (2020) Translating CKD research into primary care practice: a group-randomized study. J Gen Intern Med 35:1435–1443

    Article  PubMed  Google Scholar 

  31. Van den Bulck SA, Vankrunkelsven P, Goderis G et al (2020) Developing quality indicators for chronic kidney disease in primary care, extractable from the electronic medical record. A Rand-modified Delphi method. BMC Nephrol 21:161

    Article  PubMed  PubMed Central  Google Scholar 

  32. Delanaye P, Jager KJ, Bökenkamp A et al (2019) CKD: a call for an age-adapted definition. J Am Soc Nephrol 30:1785–1805

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Mok Y, Ballew SH, Stacey RB et al (2021) Albuminuria and prognosis among individuals with atherosclerotic cardiovascular disease: the ARIC study. J Am Coll Cardiol 78:87–89

    Article  CAS  PubMed  Google Scholar 

  34. Ghimire A, Ye F, Hemmelgarn B et al (2022) Trends in nephrology referral patterns for patients with chronic kidney disease: retrospective cohort study. PLoS ONE 17:e0272689

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Vassalotti JA, Boucree SC (2022) Integrating CKD into US primary care: bridging the knowledge and implementation gaps. Kidney International Reports 7:389–396

    Article  PubMed  PubMed Central  Google Scholar 

  36. Smith ZG, McNicoll L, Clark TL et al (2016) Medical neighborhood model for the care of chronic kidney disease patients. Am J Nephrol 44:308–315

    Article  PubMed  Google Scholar 

  37. Pesce F, Pasculli D, Pasculli G et al (2022) “The disease awareness innovation network” for chronic kidney disease identification in general practice. J Nephrol 35:2057–2065

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Taylor DM, Nimmo AM, Caskey FJ et al (2023) Complex interventions across primary and secondary care to optimize population kidney health: a systematic review and realist synthesis to understand contexts, mechanisms, and outcomes. Clin J Am Soc Nephrol 18:563–572

    Article  PubMed  Google Scholar 

  39. Raynaud J (2022) Diagnosis, assessment and challenges of access to healthcare in Occitania: preparatory work for the new zoning agreement for general practitioners. URPS report. https://www.medecin-occitanie.org/wp-content/uploads/2022/02/urps-rapport-acces-aux-soins-et-zonage-version-finale-10.02.22.pdf. Accessed 05 Oct 2022

Download references

Acknowledgements

The authors wish to thank Teresa Sawyers, medical writer at the BESPIM, Nîmes University Hospital, for the English translation of this manuscript.

Funding

The authors did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study.

Author information

Authors and Affiliations

  1. Desbrest Institute of Epidemiology and Public Health (IDESP), UMR UA11 INSERM-University of Montpellier, Montpellier, France

    Agnès Oude Engberink, Gérard Bourrel & Olivier Moranne

  2. Department of Primary Care, School of Medicine, University of Montpellier, Montpellier, France

    Agnès Oude Engberink, Guillaume Tessier, Ilham Kamil & Gérard Bourrel

  3. Nephrology-Dialysis-Apheresis Department, University Hospital of Nîmes, Place Pr Debré, Nîmes, France

    Olivier Moranne

Authors
  1. Agnès Oude Engberink
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Guillaume Tessier
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ilham Kamil
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gérard Bourrel
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Olivier Moranne
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

AOE and OM conceived the study, with developments also supported by GT and IK. AOE, GT and IK coordinated the study promotion, inclusions, and collected and transcribed the data. AOE, GT and IK analyzed and triangulated the data with the help of GB and OM. AOE and OM drafted the manuscript, with significant contributions from GB, GT and IK. All authors viewed the different versions of the manuscript and provided critical input prior to final approval.

Corresponding author

Correspondence to Olivier Moranne.

Ethics declarations

Conflict of interest

The authors declare they have no financial interests.

Ethical approval

This study was performed in line with the principles of the Declaration of Helsinki and was approved by the ethical committee of Nîmes University Hospital under the IRB number 201207.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

The authors affirm that human research participants provided informed consent for publication of this work.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 45 kb)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Oude Engberink, A., Tessier, G., Kamil, I. et al. General practitioners’ representation of early-stage CKD is a barrier to adequate management and patient empowerment: a phenomenological study. J Nephrol 37, 379–390 (2024). https://doi.org/10.1007/s40620-023-01838-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40620-023-01838-y

Keywords

Search

Navigation