Curtis Bryan M, Barrett Brendan J, Djurdjev Ognjenka, Singer Joel, Levin Adeera
Division of Nephrology and Clinical Epidemiology, Memorial University of Newfoundland, St John's, Newfoundland, Canada.
Am J Kidney Dis. 2007 Nov;50(5):733-42. doi: 10.1053/j.ajkd.2007.08.004.
Much of the comorbidity associated with chronic kidney disease (CKD) begins in the early stages. Interventions with proven efficacy exist to decrease progression, morbidity, and mortality. This study examines their use in patients with CKD before and at their first nephrologist encounter in Canada.
Prospective multicenter cohort study.
SETTING & PARTICIPANTS: 482 patients at their first nephrologist encounter enrolled from 13 Canadian centers. Inclusion criteria were measured or estimated glomerular filtration rate less than 50 mL/min/1.73 m(2). Exclusion criteria were patients with acute kidney failure or those likely to require dialysis therapy within 3 months of referral.
OUTCOMES & MEASUREMENTS: Describe: (1) characteristics of patients at their first nephrology encounter in Canada; (2) the evaluation for cardiac risk factors, cardiac diseases and CKD complications and their management before the encounter; (3) changes in management initiated by nephrologists at the first encounter; and (4) the availability and use of allied health professional services for CKD care.
Patients had a mean age of 69.7 years, estimated glomerular filtration rate of 29 mL/min/1.73 m(2) (0.48 mL/s/1.73 m(2), hemoglobin level of 12.1 g/dL (121 g/L), albumin level of 3.6 g/dL (36 g/L), and blood pressure of 147/76 mm Hg. Transmission of results from prior evaluation was variable. At the encounter, nephrologists had available or ordered albumin and calcium/phosphate tests in greater than 70% of patients. Nephrologists did not evaluate parathyroid hormone in 83% of patients, lipids in greater than 50%, iron studies (in those with anemia) in 57%, and urine studies in 30%. Despite a high prevalence of diabetes and coronary artery disease, only 46% were administered medications to interrupt the renin-angiotensin system, 37% were administered acetylsalicylic acid, and 32% were administered lipid medication after the encounter. Availability and use of allied health professional resources varied and was low in an unstructured setting.
External validity, referral bias, and inability to make causal inferences.
In Canada, patients with CKD continue to be encountered late by nephrologists (stage IV CKD). Information for prior evaluation is incompletely transmitted. Finally, there appears to be room for improvement in evaluation and treatment at the first nephrologist encounter.
许多与慢性肾脏病（CKD）相关的合并症始于疾病早期。现有已证实有效的干预措施可降低疾病进展、发病率和死亡率。本研究调查了这些干预措施在加拿大CKD患者首次就诊于肾病科医生之前及就诊时的使用情况。
前瞻性多中心队列研究。
从加拿大13个中心招募了482例首次就诊于肾病科医生的患者。纳入标准为测量或估算的肾小球滤过率低于50 mL/min/1.73 m²。排除标准为急性肾衰竭患者或转诊后3个月内可能需要透析治疗的患者。
描述：（1）加拿大患者首次就诊于肾病科时的特征；（2）就诊前对心脏危险因素、心脏病和CKD并发症的评估及其管理；（3）肾病科医生在首次就诊时启动的管理措施的变化；（4）用于CKD护理的联合健康专业服务的可及性和使用情况。
患者的平均年龄为69.7岁，估算的肾小球滤过率为29 mL/min/1.73 m²（0.48 mL/s/1.73 m²），血红蛋白水平为12.1 g/dL（121 g/L），白蛋白水平为3.6 g/dL（36 g/L），血压为147/76 mmHg。先前评估结果的传递情况各不相同。就诊时，肾病科医生为超过70%的患者进行了白蛋白和钙/磷检测或开具了相关医嘱。83%的患者，肾病科医生未评估甲状旁腺激素；超过50%的患者未评估血脂；57%的患者（贫血患者）未进行铁代谢检查；30%的患者未进行尿液检查。尽管糖尿病和冠状动脉疾病的患病率很高，但就诊后只有46%的患者接受了阻断肾素 - 血管紧张素系统的药物治疗，37%的患者接受了乙酰水杨酸治疗，32%的患者接受了降脂药物治疗。联合健康专业资源的可及性和使用情况各不相同，在非结构化环境中较低。
外部效度、转诊偏倚以及无法进行因果推断。
在加拿大，肾病科医生诊治CKD患者仍较晚（CKD 4期）。先前评估的信息传递不完整。最后，在首次就诊于肾病科医生时的评估和治疗方面似乎仍有改进空间。
