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Chronic kidney disease deserves specialty care.

NEW ORLEANS -- Patients in the middle to later stages of chronic kidney disease who are referred to a nephrologist have longer progression-free survival than those being treated by a primary care provider, a retrospective study has shown.

During the earliest stages of renal dysfunction, however, there are no survival differences between patients who see a nephrologist and those who see a primary care provider, Lori A. Orlando, M.D., said at the annual meeting of the Society of General Internal Medicine.

Nephrologists have long reported that late referral of patients with chronic kidney disease can adversely affect clinical outcome by delaying the introduction of therapeutic measures and potentially exacerbating uremic complications.

Dr. Orlando and her colleagues at Duke University, Durham, N.C., reviewed the clinical outcomes of 1,553 veterans with chronic kidney disease, 1,097 of whom were treated by primary care physicians only and 456 of whom were referred to nephrologists at some point.

"There were no morbidity and mortality differences between the two groups during stages 1 and 2 [see box], but referral by stage 3 significantly attenuated the progressive loss of kidney function and delayed end-stage renal failure," she reported.

The study included male patients, mean age 70 years, with primary care providers at the local veterans' hospital. During a 2-year period, each patient had two abnormal serum creatinine levels at least 3 weeks apart.

The investigators gathered 5 years of follow-up data on disease course, complications, medications, comorbidities, and mortality. To evaluate disease course, they used a Cox proportional hazards model adjusted for demographics, comorbidities, medications, and a propensity score for both the primary care and referral groups. "We used the propensity score to adjust for bias in patients referred to nephrologists," she said.

Overall, the mean number of days spent in each stage of disease was 1,149 for stage 1; 1,206 for stage 2; 1,158 for stage 3; 794 for stage 4; and 709 for stage 5. Slowed disease progression was independently associated with the use of angiotensin-converting enzyme inhibitors and with the use of statins. The presence of vascular disease and hemoglobin [A.sub.1c] values greater than 7% were both independently associated with accelerated disease progression.

After controlling for these associations, a comparison of disease course between the referral and primary care groups showed no difference in survival during stage 1 or 2, "but during stages 3-5, patients in the nephrology group spent an average of 152 days more in each stage," she said.

These numbers are significant given the increasing prevalence of renal disease, which currently affects about 11% of the population--or 20 million people--in this country, Dr. Orlando said. "The first question to ask is why patients are being referred so late, or not being referred at all."

Among the possibilities, she noted, is the lack of sufficient numbers of specialists to meet the growing need. Also, patients may choose not to seek specialty care because they feel more comfortable with their primary care physician or because of logistical concerns about getting to specialty appointments. Finally, primary care physicians may not have enough clinical experience to assess disease stage and provide optimal follow-up, and may have the misperception that nephrologists need to be brought into the picture only when dialysis is required.

The more pressing questions, she said, are "which aspects of specialty care improve the management of chronic kidney disease and increase the survival of these patients, and how do we implement them in a primary care or integrated care setting?"

Nephrologists probably are more attuned to spotting early signs of acute complications, such as fluid overload, arterial hypertension, pericarditis, or gastrointestinal complications from anemia. Failure to detect and address these complications can lead to emergency dialysis and worse outcomes, Dr. Orlando said.

Prospective studies are needed to clarify the role of nephrologists in the early stages of chronic kidney disease, she stressed. "We also need improved collaboration between primary care providers and nephrologists in order to provide optimal care. Nephrologists have the specialized knowledge and insight, and primary care providers have the patients. They have to come together in ways that make sense."

BY DIANA MAHONEY

New England Bureau
Stages of Chronic Kidney Disease

Stage Kidney Status GFR (mL/min)

Normal kidney Healthy kidney [greater than or equal to]90
 function
Stage 1 Kidney damage, normal to [greater than or equal to]90
 high GFR
Stage 2 Kidney damage, mild 60-89
 decrease in GFR
Stage 3 Moderate decrease in GFR 30-59
Stage 4 Severe decrease in GFR 15-29
Stage 5 Kidney failure <15 or on dialysis

Note: Chronic kidney disease is defined by the presence of a kidney-
damage marker, and decreased kidney function as measured by the
glomerular filtration rate (GFR) for 3 months or longer.
Source: National Kidney Foundation
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Title Annotation:nephrologist services
Author:Mahoney, Diana
Publication:Internal Medicine News
Geographic Code:1U7LA
Date:Jun 15, 2005
Words:796
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