Weltman Melanie R, Lavenburg Linda-Marie U, Han Zhuoheng, Alghwiri Alaa A, Mosslemi Mitra, Rollman Bruce L, Fischer Gary S, Nolin Thomas D, Yabes Jonathan G, Jhamb Manisha
Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania.
J Am Soc Nephrol. 2025 May 1;36(5):869-881. doi: 10.1681/ASN.0000000544. Epub 2024 Nov 1.
Implementation gaps in guideline-concordant care for CKD are associated with poor clinical outcomes. A population health management–based, multidisciplinary approach improved exposure days to sodium-glucose cotransporter-2 inhibitor and glucagon-like peptide-1 receptor agonists compared with usual care. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in albuminuric patients and statin use was not improved, nor was BP control, glycemic control, or albuminuria testing.
Gaps in guideline-concordant care for CKD lead to poor outcomes. The Kidney Coordinated HeAlth Management Partnership (K-CHAMP) cluster randomized trial tested the effect of a population health management intervention versus usual care on CKD progression and evidence-based care delivery in the primary care setting.
K-CHAMP included adults aged 18–85 years with eGFR<60 ml/min per 1.73 m and moderate-high risk of CKD progression who were not seeing a nephrologist. The multifaceted intervention included nephrology e-consult, pharmacist-led medication management, and patient education. In this analysis, we evaluate the effectiveness of K-CHAMP on guideline-concordant care processes (BP and glycemic control, annual albuminuria testing) and medication exposure days (angiotensin-converting enzyme inhibitor [ACEi]/angiotensin receptor blocker [ARB], moderate-high intensity statin, sodium-glucose cotransporter-2 inhibitor [SGLT2i], glucagon-like peptide-1 receptor agonists [GLP-1RA]). Given multiplicity of outcomes, Benjamini–Hochberg method was used to control false discovery rate.
All 1596 (754 intervention, 842 usual care) enrolled patients (mean age 74±9 years, eGFR 37±8 ml/min per 1.73 m, 928 [58%] female, 127 [8%] Black) were analyzed. After a median 17-month follow-up, intervention arm patients had significantly higher exposure days per year to SGLT2i (56 versus 32 days; relative benefit 1.72; 95% confidence interval [CI], 1.14 to 2.30) and GLP-1RA (78 versus 29 days; relative benefit 2.65; 95% CI, 1.59 to 3.71) compared with usual care in adjusted analysis. At study initiation in 2019, similar proportion of patients were prescribed SGLT2i and/or GLP-1RA in intervention and control arm (8% versus 6%, respectively; rate ratio 1.23; 95% CI, 0 to 2.99), but by 2022, prescription of these medications was significantly higher in intervention arm (44% versus 27%, respectively; rate ratio 1.63; 95% CI, 1.32 to 1.94). There was no significant difference in any process measures or exposure days to ACEi/ARB in patients with albuminuria or moderate-high intensity statin.
K-CHAMP was effective in accelerating implementation of SGLT2i and GLP-1RA but did not increase ACEi/ARB in patients with albuminuria or moderate-high intensity statin use or improve BP control, glycemic control, or albuminuria testing in individuals with CKD in the primary care setting.
: K-CHAMP, NCT03832595.
慢性肾脏病（CKD）指南一致性治疗中的实施差距与不良临床结局相关。与常规治疗相比，基于人群健康管理的多学科方法增加了钠-葡萄糖协同转运蛋白2抑制剂（SGLT2i）和胰高血糖素样肽-1受体激动剂（GLP-1RA）的使用天数。白蛋白尿患者使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂以及他汀类药物的使用情况并未改善，血压控制、血糖控制或白蛋白尿检测情况也未改善。
CKD指南一致性治疗中的差距导致不良结局。肾脏协调健康管理合作项目（K-CHAMP）集群随机试验在初级医疗环境中测试了人群健康管理干预与常规治疗对CKD进展和循证治疗实施的影响。
K-CHAMP纳入了年龄在18至85岁、估算肾小球滤过率（eGFR）<60 ml/（min·1.73 m²）且有中高CKD进展风险、未就诊于肾病科的成年人。多方面干预措施包括肾病电子会诊、药剂师主导的药物管理和患者教育。在本分析中，我们评估K-CHAMP对指南一致性治疗过程（血压和血糖控制、年度白蛋白尿检测）和药物使用天数（血管紧张素转换酶抑制剂[ACEi]/血管紧张素受体阻滞剂[ARB]、中高强度他汀类药物、SGLT2i、GLP-1RA）的有效性。鉴于结局的多样性，采用Benjamini-Hochberg方法控制假发现率。
对所有1596名（754名干预组，842名常规治疗组）入组患者（平均年龄74±9岁，eGFR 37±8 ml/（min·1.73 m²），928名[58%]为女性，127名[8%]为黑人）进行了分析。经过中位17个月的随访，在调整分析中，干预组患者每年使用SGLT2i的天数显著多于常规治疗组（56天对32天；相对获益1.72；95%置信区间[CI]，1.14至2.30），使用GLP-1RA的天数也显著多于常规治疗组（78天对29天；相对获益2.65；95% CI，1.59至3.71）。在2019年研究开始时，干预组和对照组中开具SGLT2i和/或GLP-1RA处方的患者比例相似（分别为8%对6%；率比1.23；95% CI，0至2.99），但到2022年，干预组这些药物的处方率显著更高（分别为44%对27%；率比1.63；95% CI，1.32至1.94）。在白蛋白尿患者或使用中高强度他汀类药物的患者中，任何治疗过程指标或ACEi/ARB的使用天数均无显著差异。
K-CHAMP在加速SGLT2i和GLP-1RA的应用方面有效，但在初级医疗环境中，并未增加白蛋白尿患者使用ACEi/ARB或中高强度他汀类药物的比例，也未改善CKD患者的血压控制、血糖控制或白蛋白尿检测情况。
K-CHAMP，NCT03832595。
