Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
Am J Nephrol. 2021;52(12):949-957. doi: 10.1159/000519758. Epub 2021 Dec 7.
The prevalence of chronic kidney disease (CKD) in Medicare beneficiaries has quadrupled in the past 2 decades, but little is known about risk factors affecting the progression of CKD. This study aims to understand the progression in Medicare Advantage enrollees and whether it differs by provider recognition of CKD, race and ethnicity, or geographic location. In a large cohort of Medicare Advantage (MA) enrollees, we examined whether CKD progression, up to 5 years after study entry, differed by demographic and clinical factors and identified additional risk factors of CKD progression.
In a cohort of 1,002,388 MA enrollees with CKD stages 1-4 based on 2013-2018 labs, progression was estimated using a mixed-effects model that adjusted for demographics, geographic location, comorbidity, urine albumin-to-creatinine ratio, clinical recognition via diagnosed CKD, and time-fixed effects. Race and ethnicity, geographic location, and clinical recognition of CKD were interacted with time in 3 separate regression models.
Mean (median) follow-up was 3.1 (3.0) years. Black and Hispanic MA enrollees had greater kidney function at study entry than other beneficiaries, but their kidney function declined faster. MA enrollees with clinically recognized CKD had estimated glomerular filtration rate levels that were 18.6 units (95% confidence interval [CI]: 18.5-18.7) lower than levels of unrecognized patients, but kidney function declined more slowly in enrollees with clinical recognition. There were no differences in CKD progression by geography. After removal of the race coefficient from the eGFR equation in a sensitivity analysis, kidney function was much lower in all years among Black MA enrollees, but patterns of progression remained the same.
DISCUSSION/CONCLUSIONS: These results suggest that patients with clinically recognized CKD and racial and ethnic minorities merit closer surveillance and management to reduce their risk of faster progression.
在过去的 20 年中，医疗保险受益人的慢性肾脏病（CKD）患病率增加了四倍，但对于影响 CKD 进展的风险因素知之甚少。本研究旨在了解医疗保险优势计划（MA）参保者的进展情况，以及是否因 CKD 的临床识别、种族和族裔或地理位置而有所不同。在一项大型医疗保险优势计划（MA）参保者队列中，我们检查了 CKD 进展情况（在研究入组后长达 5 年）是否因人口统计学和临床因素而有所不同，并确定了 CKD 进展的其他危险因素。
在基于 2013-2018 年实验室检查的 1002388 例 CKD 1-4 期 MA 参保者队列中，使用混合效应模型估计进展情况，该模型调整了人口统计学、地理位置、合并症、尿白蛋白与肌酐比值、通过诊断 CKD 进行的临床识别以及时间固定效应。在三个单独的回归模型中，种族和族裔、地理位置和 CKD 的临床识别与时间相互作用。
平均（中位数）随访时间为 3.1（3.0）年。黑人及西班牙裔 MA 参保者在研究入组时的肾功能优于其他受益人群，但肾功能下降更快。在临床识别的 CKD 患者中，估计肾小球滤过率（eGFR）水平比未识别患者低 18.6 个单位（95%置信区间[CI]：18.5-18.7），但在临床识别的患者中，肾功能下降速度较慢。在地理位置方面，CKD 进展没有差异。在敏感性分析中从 eGFR 方程中去除种族系数后，黑人 MA 参保者所有年份的肾功能都低得多，但进展模式保持不变。
讨论/结论：这些结果表明，临床识别的 CKD 患者和少数民族患者需要更密切的监测和管理，以降低其进展更快的风险。
