Chronic Kidney Disease

High prevalence of uncontrolled hypertension and diabetes is seen in chronic kidney disease (CKD)  patients; as well as statin use below the recommended guidelines for cholesterol control; according to a study by researchers at UC San Francisco. But effective treatments exist for the more than 30 million Americans with CKD; nearly 50 % of such patients analyze from 2006 to 2014 continue to suffer from uncontrolled hypertension; and about 40 %  of them  suffer from uncontrolled diabetes, the researchers said.

“Even when physicians are aware of a patient’s CKD diagnosis; there are substantial gaps in quality of care,” said lead author Sri Lekha Tummalapalli, MD, MBA, a nephrology fellow at UCSF. “The lack of improvement over a decade highlights a more urgent need for CKD-specific quality measures; and the implementation of quality-improvement interventions.”

Chronic kidney disease

CKD, a condition of reduced kidney function or kidney damage; affects about 13.6 % of the U.S. adult population and is expected to grow to 14.4 % by 2020 and 16.7 % by 2030. Combined with end-stage renal disease (ESRD); it results in high morbidity, mortality and health care costs.

According to the U.S. Renal Data System, among fee-for-service Medicare patients; total medical costs in 2016 exceeded $79 billion for CKD and another $35 billion for ESRD patients. However, CKD management is complex, involving multiple interventions to protect patient health and prevent kidney failure; such as lifestyle changes and/or medications that control hypertension, high cholesterol and diabetes.

In the study, Tummalapalli and her colleagues used the National Ambulatory Medical Care Survey; to review visits by CKD patients to office-based outpatient practices over a nine-year period. They reviewed blood pressure measurement, uncontrolled hypertension and uncontrolled diabetes; as well as the use of certain medications in patients with hypertension, statins if aged 50 years and older; and nonsteroidal anti-inflammatory drugs (NSAIDs).

Prevalence of uncontrolled hypertension

Overall, they assessed 7,099 visits for CKD patients. No statistically significant difference was found in the prevalence of uncontrolled hypertension; over time: 46 %in 2006-2008 to 48 % in 2012-2014. They also found that 40 % of the patients had uncontrolled diabetes in 2012-2014.

NSAID use recorded in the medical record was low; averaging 3 % from 2006 to 2014. Statin use in CKD patients aged 50 years and older with high cholesterol was low; and statistically unchanged during the study period, from 29 % in 2006-2008 to 31 % in 2012-2014; despite guidelines for their use by the American College of Cardiology and the American Heart Association.

The researchers cited a lack of dedicated; specific quality metrics and insufficient knowledge of specific guidelines for the overall poor quality of CKD care. Low rates of nephrology referral may further drive decreased; adherence to quality indicators, they said, along with payment models and care delivery systems; that do not support population health-based interventions.

Efforts towards improved CKD

Most CKD is treat in primary care settings, so efforts towards improved CKD management; must involve primary care physicians as a central component of multi specialty care teams, Tummalapalli said, while addressing their limited time and competing demands.

“Chronic disease management in all patients, and particularly those with CKD; is essential to slow disease progression; and reduce the risk of kidney failure and cardiovascular events,” Tummalapalli said. “Improving the control of hypertension and diabetes is extremely challenging; and requires multifaceted efforts to deliver care more effectively and support lifestyle modification and medication adherence.