Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
PLoS One. 2022 Aug 11;17(8):e0272689. doi: 10.1371/journal.pone.0272689. eCollection 2022.
Information on early, guideline discordant referrals in nephrology is limited. Our objective was to investigate trends in referral patterns to nephrology for patients with chronic kidney disease (CKD).
Retrospective cohort study of adults with ≥1 visits to a nephrologist from primary care with ≥1 serum creatinine and/or urine protein measurement <180 days before index nephrology visit, from 2006 and 2019 in Alberta, Canada. Guideline discordant referrals were those that did not meet ≥1 of: Estimated glomerular filtration rate (eGFR) ˂ 30 mL/min/1.73m2, persistent albuminuria (ACR ≥ 300 mg/g, PCR ≥ 500 mg/g, or Udip ≥ 2+), or progressive and persistent decline in eGFR until index nephrology visit (≥ 5 mL/min/1.73m2).
Of 69,372 patients with CKD, 28,518 (41%) were referred in a guideline concordant manner. The overall rate of first outpatient visits to nephrology increased from 2006 to 2019, although guideline discordant referrals showed a greater increase (trend 21.9 per million population/year, 95% confidence interval 4.3, 39.4) versus guideline concordant referrals (trend 12.4 per million population/year, 95% confidence interval 5.7, 19.0). The guideline concordant cohort were more likely to be on renin-angiotensin system blockers or beta blockers (hazard ratio 1.14, 95% confidence interval 1.12, 1.16), and had a higher risk of CKD progression (hazard ratio 1.09, 95% confidence interval 1.06, 1.13), kidney failure (hazard ratio 7.65, 95% confidence interval 6.83, 8.56), cardiovascular event (hazard ratio 1.40, 95% confidence interval 1.35,1.45) and mortality (hazard ratio 1.58, 95% confidence interval 1.52, 1.63).
A significant proportion nephrology referrals from primary care were not consistent with current guideline-recommended criteria for referral. Further work is needed to identify quality improvement initiatives aimed at enhancing referral patterns of patients with CKD.
有关肾脏病学中早期与指南不符的转诊信息有限。我们的目的是调查慢性肾脏病（CKD）患者向肾脏病学转诊的模式趋势。
这是一项在加拿大艾伯塔省进行的回顾性队列研究，纳入了 2006 年至 2019 年期间在初级保健机构至少就诊 1 次且在索引肾脏就诊前<180 天内至少有 1 次血清肌酐和/或尿蛋白测量值的成年人，这些患者至少有 1 次就诊至肾脏病学。指南不一致的转诊是指不符合以下至少 1 项标准的转诊：估计肾小球滤过率（eGFR）<30mL/min/1.73m2，持续白蛋白尿（ACR≥300mg/g、PCR≥500mg/g 或 Udip≥2+），或 eGFR 持续且进行性下降至索引肾脏就诊（≥5mL/min/1.73m2）。
在 69372 例 CKD 患者中，28518 例（41%）以指南一致的方式转诊。首次到肾脏科门诊就诊的总人数从 2006 年到 2019 年有所增加，尽管指南不一致的转诊显示出更大的增加（趋势为每百万人口每年 21.9 例，95%置信区间为 4.3 例至 39.4 例），而指南一致的转诊则为每百万人口每年 12.4 例（趋势为每百万人口每年 12.4 例，95%置信区间为 5.7 例至 19.0 例）。指南一致的队列更有可能使用肾素-血管紧张素系统阻滞剂或β受体阻滞剂（风险比 1.14，95%置信区间 1.12，1.16），并且发生 CKD 进展的风险更高（风险比 1.09，95%置信区间 1.06，1.13），肾衰竭（风险比 7.65，95%置信区间 6.83，8.56），心血管事件（风险比 1.40，95%置信区间 1.35，1.45）和死亡率（风险比 1.58，95%置信区间 1.52，1.63）。
从初级保健机构向肾脏病学转诊的很大一部分不符合当前指南推荐的转诊标准。需要进一步开展工作，以确定旨在改善 CKD 患者转诊模式的质量改进举措。
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