VA 医疗保健系统初级保健诊所的慢性肾脏病筛查和识别。
Screening and Recognition of Chronic Kidney Disease in VA Health Care System Primary Care Clinics.
机构信息
Division of Nephrology, Department of Medicine, University of Texas Health at San Antonio, San Antonio, Texas.
South Texas Veterans Healthcare System, San Antonio, Texas.
出版信息
Kidney360. 2020 Jul 9;1(9):904-915. doi: 10.34067/KID.0000532020. eCollection 2020 Sep 24.
BACKGROUND
The successful implementation of interventions targeted to improve kidney health requires early identification of CKD which involves screening at-risk populations as well as recognizing CKD. We aim to determine CKD screening and recognition rates, factors associated with these rates, and evaluate the effect of CKD awareness on delivery of care.
METHODS
A retrospective cohort study of veterans enrolled with Veterans Integrated Service Network 17 who had hypertension (HTN) and/or diabetes (DM) and were seen at least twice in primary care clinics within 18 months. The final cohort of 270,170 patients (52% HTN, 5% DM, and 44% both) was examined for serum creatinine/eGFR, urine protein/albumin, International Classification of Diseases (ICD) codes for CKD, and nephrology referral. CKD was defined as eGFR <60 ml/min per 1.73 m and/or urine albumin-creatinine ratio (uACR) >30 mg/g at least twice 90 days apart. Clinical covariates, HTN control, and prescription rates of renal prudent medications and nonsteroidal anti-inflammatory drugs (NSAIDs) were assessed.
RESULTS
Overall, 254,831 (94%) patients had either eGFR, urine protein/albumin, or both. However, screening for protein/albuminuria was low (56%), particularly in patients with isolated HTN (35%). Of 254,831 patients, 92,900 (36%) had laboratory evidence of CKD and, of these, 40,586 (44%) were recognized to have CKD by ICD code and/or nephrology referral. CKD due to presence of uACR criteria alone had the lowest recognition (19%) as compared with CKD due to eGFR criteria (44%) or both (67%). Frequency of emergency room visits, hospitalization, and cardiac and endovascular procedures requiring contrast had the highest odds and races other than white had the lower odds of screening. In contrast, CKD recognition was high in races other than white and increased with worsening eGFR and increasing uACR. In screened and recognized CKD, prescription was higher for angiotensin inhibitors, statins, and diuretics, and was lower for NSAIDs.
CONCLUSIONS
Although overall CKD screening rate was high, screening of protein/albuminuria in isolated HTN and overall recognition of CKD was low in at-risk veterans. Increased recognition was associated with a favorable prescription rate for renal prudent medications.
背景
为了提高肾脏健康，需要对目标人群进行干预，这就需要早期识别慢性肾脏病（CKD），包括对高危人群进行筛查以及对 CKD 进行识别。本研究旨在确定 CKD 的筛查和识别率，以及与这些率相关的因素，并评估 CKD 知晓率对治疗效果的影响。
方法
这是一项针对退伍军人的回顾性队列研究，纳入了 Veterans Integrated Service Network 17 网络下的高血压（HTN）和/或糖尿病（DM）患者，这些患者在 18 个月内至少两次在初级保健诊所就诊。在最终的 270170 例患者中（52%为 HTN，5%为 DM，44%同时患有 HTN 和 DM），对血清肌酐/估计肾小球滤过率（eGFR）、尿蛋白/白蛋白、国际疾病分类（ICD）编码的 CKD 以及肾脏科转介进行了检查。CKD 定义为 eGFR<60ml/min/1.73m2 和/或尿白蛋白/肌酐比值（uACR）>30mg/g，且至少两次相隔 90 天。评估了临床协变量、HTN 控制情况以及保肾药物和非甾体抗炎药（NSAIDs）的处方率。
结果
总体而言，254831 例患者（94%）有 eGFR、尿蛋白/白蛋白或两者均有。然而，尿蛋白/白蛋白筛查率较低（56%），特别是在单纯 HTN 患者中（35%）。在 254831 例患者中，92900 例（36%）有实验室证据表明存在 CKD，其中 40586 例（44%）通过 ICD 编码和/或肾脏科转介被识别为 CKD。由于 uACR 标准而导致的 CKD 识别率最低（19%），而由于 eGFR 标准（44%）或两者（67%）而导致的 CKD 识别率较高。急诊就诊、住院、需要造影的心脏和血管内手术的频率以及非白色人种的种族与较低的筛查率相关。相比之下，非白色人种的 CKD 识别率较高，并且随着 eGFR 的恶化和 uACR 的增加而增加。在筛查和识别的 CKD 患者中，血管紧张素抑制剂、他汀类药物和利尿剂的处方率较高，而非甾体抗炎药的处方率较低。
结论
尽管总体 CKD 筛查率较高，但在高危退伍军人中，孤立性 HTN 患者的尿蛋白/白蛋白筛查率较低，对 CKD 的整体识别率也较低。提高识别率与使用保肾药物的处方率增加相关。
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