Similar quality in chronic kidney disease multidisciplinary follow-up between kidney

Carminatti, Moisés; Fernandes, Natália Maria Silva; Colugnati, Fernando Antonio Basile; Sanders-Pinheiro, Helady

doi:10.1590/2175-8239-JBN-2019-0239

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Brazilian Journal of Nephrology

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Original Article • J. Bras. Nefrol. 43 (3) • Jul-Sep 2021 • https://doi.org/10.1590/2175-8239-JBN-2019-0239 copy

Similar quality in chronic kidney disease multidisciplinary follow-up between kidney

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Multidisciplinary clinics are the best approach towards Chronic Kidney Disease (CKD) patients in pre-dialysis phases. The few studies regarding kidney transplant recipients (KTR) compare multidisciplinary and non-multidisciplinary clinics.

Methods:

In this study, we compared the quality of multidisciplinary CKD care between 101 KTR and 101 propensity score-matched non-transplant pre-dialysis patients (PDP). Prevalence of patients without specific treatment at any time and percent time without specific treatment for CKD complications were the main outcomes and patient and kidney function survival, glomerular filtration rate (GFR) decline, prevalence of CKD-related complications, and percent time within therapeutic goals were the exploratory ones.

Results:

Time within most goals was similar between the groups, except for diastolic blood pressure (83.4 vs. 77.3%, RR 0.92, CI 0.88-0.97, p = 0.002) and hypertriglyceridemia (67.7 vs. 58.2%, OR 0.85, CI 0.78-0.93, p < 0.001), better in non-transplant PDP, and for proteinuria (92.7 vs. 83.5%, RR 1.1, CI 1.05-1.16, p < 0.001), better in KTR. Patient survival and GFR decline were similar between the groups, although non-transplant PDP tended to progress earlier to dialysis (9.9% vs. 6.9%, HR 0.39, p = 0.07, CI 0.14-1.08).

Discussion:

The similar findings between non-transplant PDP and KTR suggests that good and comparable quality of multidisciplinary is a valid strategy for promoting optimal clinical management of CKD-related complications in KTR.

Keywords:
Renal Insufficiency, Chronic; Kidney Transplantation; Patient Care Team; Health Services Research; Graft Survival.

	NT-PDP (N = 101)	KTR (N = 101)	P
Demographics
Age (years)	50.2 ± 13.5	43.4 ± 12.5	<0.001
Female sex (%)	37.6	31.7	0.46
Caucasian race (%)	54.4	74.2	0.003
Body mass index (kg/m²)	26.18	24.78	0.025
Follow-up (months)	31.61	55.77	<0.001
Renal function
Creatinine (mg/dL)	1.62 ± 0.61	1.59 ± 0.53	0.735
eGFR (mL/min/1.73m²)	51.69 ± 20.18	53.27 ± 16.88	0.548
CKD category at baseline (%)			0.509
1	2.9	2.9
2	24.8	29.7
3a	40.6	36.6
3b	22.8	24.8
4	8.9	5.9
5	0	0
Primary cause of CKD (%)			0.397
Hypertensive	43.6	20.8
Glomerulonephritis	12.9	40.6
Diabetes	4.0	2.0
Adult polycystic kidney disease	11.9	5.0
Other	6.9	5.9
Undetermined	20.8	25.7
Comorbidities at Baseline (%)
Hypertension	92.1	86.1	0.175
Diabetes	4.95	2.97	0.251
Obesity	20.8	11.9	0.088
Coronary artery disease	6.93	6.93	1.0
Peripheral artery disease	2.97	0.99	0.315
Cerebrovascular disease	4.95	1.98	0.251
Congestive heart failure	5.94	3.96	0.519
Smoking	9.9	8.9	0.808
Baseline clinical characteristics
Systolic blood pressure (mmHg)	137.6 ± 25.3	125.1 ± 13.1	<0,001
Diastolic blood pressure (mmHg)	85.5 ± 13.9	80.0 ± 11.0	0.002
Haemoglobin (g/dL)	13.5 ± 1.5	12.7 ± 1.67	< 0.001
Proteinuria (mg/24h)	169(10-5650)	184(15-1500)	0.071
Total cholesterol (mg/dL)	189.8 ± 43.4	186.6 ± 37.8	0.598
LDL cholesterol (mg/dL)	115.0 ± 35.8	109.7 ± 28.3	0.291
HDL cholesterol (mg/dL)	50.4 ± 14.7	46.4 ± 13.5	0.056
Triglycerides (mg/dL)	138.1 ± 78.1	151.4 ± 96.8	0.33
Calcium (mg/dL)	9.4 ± 0.7	9.7 ± 0.7	0.033
Phosphorus (mg/dL)	3.6 ± 0.7	3.4 ± 0.8	0.124
PTH (pg/mL)	63 (7.6-784)	76.7 (19-530)	0.886
Cholecalciferol (ng/mL)	23.5 (2-42)	24.4 (16.7-38)	0.872
Albumin (g/dL)	4.0 ± 0.5	4.2 ± 0.5	0.144
Bicarbonate (mEq/L)	24.6 ± 3.6	23.3 ± 2.6	0.113
Uric Acid (mg/dL)	6.6 ± 1.6	6.3 ± 1.5	0.246
Overall use of key medications (%)
Anti-hypertensives	94.0	90.1	0.298
ACEi or ARB	87.1	78.2	0.127
Betablockers	45.5	38.6	0.32
ASA	17.8	15.8	0.707
Statins	49.5	61.3	0.092
Phosphate binder	5.94	4.95	0.757
1,25 OH Vitamin D	4.95	2.97	0.476
Cholecalciferol	48.5	2.97	< 0.001
Erythropoietin	3.96	28.7	< 0.001
Bicarbonate	14.8	19.8	0.355
Allopurinol	16.8	10.9	0.227

Donor Type (%)
Living related	84.2
Living unrelated	11.9
Deceased	3.9

HLA matches (%)
0-2	26.7
3	54.5
6	18.8
Median time on dialysis (months)	20 (0 – 112, 12 preemptive transplants)
Complications during follow-up (%)
Delayed graft function	5.94
Acute rejection	9.9
Post-transplant Diabetes	17.8
Immunosuppression (%)
Prednisone	89.1
Tacrolimus	56.4
Cyclosporine	23.7
Mycophenolate	73.2
Azathioprine	26.7
Rapamycin	32.6
Everolimus	8.9
Triple medication	89.1
Calcineurin inhibitor	79.1

	NT-PDP (%)	KTR (%)	RR/OR	CI	p
Hypertension and blood pressure control
Baseline systolic hypertension	92.1	85.1	0.49^* * OR (odds ratio).	0.19-1.22	0.126
Systolic hypertension in follow-up	94.1	92.1	0.97	0.9-1.05	0.579
Systolic BP within goal	75.7	76.5	1.01	0.95-1.06	0.695
Baseline diastolic hypertension	92.1	86.1	0.53^* * OR (odds ratio).	0.21-1.33	0.18
Diastolic hypertension in follow-up	94.1	93.1	0.98	0.92-1.06	0.774
Diastolic BP within goal	83.4	77.3	0.92	0.88-0.97	0.002
Proteinuria and anaemia
Baseline proteinuria > 1g/day	11.8	7.9	0.64^* * OR (odds ratio).	0.24-1.67	0.36
Proteinuria > 1g/day in follow-up	22.6	23.7	1.05	0.62-1.75	0.845
Patients with untreated proteinuria	3.2	6.9	2.14	0.57-8.06	0.257
Time with untreated proteinuria	7.5	17.2	2.27	0.76-6.73	0.137
Proteinuria within goal	83.5	92.7	1.1	1.05-1.16	< 0.001
Baseline anaemia	6.9	22.8	3.95^* * OR (odds ratio).	1.61-9.71	0.002
Anemia in follow-up	15.8	38.6	2.43	1.46-4.06	< 0.001
Patients with untreated anemia	13.8	16.8	1.21	0.63-2.32	0.559
Time with untreated anemia	73.9	11.3	0.15	0.1-0.23	< 0.001
Hemoglobin within goal	92.0	92.8	1.008	0.97-1.03	0.614
Lipid abnormalities
Baseline hypercholesterolemia	61.4	59.4	0.92^* * OR (odds ratio).	0.52-1.61	0.774
Hypercholesterolemia in follow-up	76.2	78.2	1.02	0.88-1.19	0.737
Patients with untreated Hypercholesterolemia	40.6	38.6	0.95	0.67-1.33	0.773
Time with untreated hypercholesterolemia	22.9	15.7	0.68	0.52-0.89	0.005
Total cholesterol within goal	66.4	69.9	1.05	0.97-1.13	0.188
Baseline elevated LDL cholesterol	82.0	76.2	0.7^* * OR (odds ratio).	0.35-1.39	0.316
Elevated LDL cholesterol in follow-up	92.0	88.1	0.95	0.87-1.05	0.358
Patients with untreated elevated LDL	60.6	51.5	0.83	0.65-1.06	0.15
Time with untreated elevated LDL	35.6	31.0	0.87	0.73-1.03	0.117
LDL cholesterol within goal	40.3	45.7	1.13	0.98-1.3	0.07
Baseline hypertriglyceridemia	28.0	37.6	1.55^* * OR (odds ratio).	0.85-2.8	0.147
Hypertriglyceridemia in follow-up	51.0	78.2	1.53	1.23-1.9	< 0.001
Triglyceridemia within goal	67.7	58.2	0.85	0.78-0.93	< 0.001
Bone mineral disorder
Baseline hyperphosphatemia	5.5	4.9	0.89^* * OR (odds ratio).	0.25-3.2	0.865
Hyperphosphatemia in follow-up	12.7	19.8	1.55	0.8-2.99	0.191
Patients w/ untreated hyperphosphatemia	7.4	18.8	2.52	1.11-5.73	0.026
Time with untreated hyperphosphatemia	30.0	56.1	1.86	1.01-3.44	0.044
Phosphataemia within goal	94.9	95.5	1.006	0.97-1.03	0.654
Baseline hyperparathyroidism	1.4	2.9	2.05^* * OR (odds ratio).	0.18-23.2	0.559
Hyperparathyroidism in follow-up	5.7	4.3	0.76	0.17-3.27	0.713
Patients with untreated hyperparathyroidism	2.8	4.4	1.52	0.26-8.82	0.639
Time with untreated hyperparathyroidism	30.0	25.0	0.83	0.24-2.8	0.768
PTH within goal	95.3	95.7	1.003	0.95-1.05	0.873
Baseline hypovitaminosis D	76.1	59.2	0.45^* * OR (odds ratio).	0.18-1.13	0.091
Hypovitaminosis D in follow-up	84.1	77.8	0.92	0.74-1.15	0.489
Patients with untreated hypovitamin D	53.4	66.6	1.24	0.89-1.73	0.188
Time with untreated hypovitamin D	28.3	33.3	1.17	0.82-1.68	0.368
25-OH Vitamin D within goal	39.2	49.4	1.25	0.96-1.64	0.09
Other metabolic parameters
Baseline hyperuricemia	30.3	14.0	0.37^* * OR (odds ratio).	0.18-0.76	0.006
Hyperuricemia in follow-up	40.4	39.0	0.96	0.68-1.35	0.839
Patients with untreated hyperuricemia	28.3	34.0	1.2	0.79-1.82	0.385
Time with untreated hyperuricemia	35.4	60.4	1.7	1.31-2.21	< 0.001
Uricemia within goal	83.9	87.2	1.03	0.98-1.09	0.146
Baseline metabolic acidosis	17.5	19.4	1.13^* * OR (odds ratio).	0.46-2.78	0.783
Metabolic acidosis in follow-up	28.1	34.7	1.23	0.73-2.08	0.425
Patients with untreated metabolic acidosis	3.5	12.5	3.56	0.8-15.84	0.095
Time with untreated metabolic acidosis	2.6	8.5	3.3	0.74-14.7	0.116
Serum bicarbonate within goal	86.4	90.1	1.04	0.96-1.13	0.316

	NT-PDP progressed to dialysis (N = 10)	NT-PDP not progressed to dialysis (N = 91)	KTR progressed to dialysis (N = 7)	KTR not progressed to dialysis (N = 94)
Primary cause of CKD
Glomerulonephritis	60.0	7.7	57.1	39.3
Hypertension	20.0	46.1	0.0	22.3
Diabetes	10.0	3.3	14.3	1.1
Polycystic kidney disease	0.0	13.2	0.0	5.3
Other	10.0	6.6	14.3	5.3
Undetermined	0.0	23.1	14.3	26.6
Baseline renal function
Creatinine (mg/dL)	2.58 ± 0.89	1.51 ± 0.47	2.24 ± 1.00	1.54 ± 0.45
eGFR (mL/min/1.73m²)	33.4 ± 12.4	53.7 ± 19.9	37.23 ± 13.0	54.4 ± 16.6
Demographics
Female gender (%)	30.0	38.5	57.1	29.8
Age (years)	36.6 ± 11.0	51.8 ± 12.9	36.3 ± 11.8	43.9 ± 12.5
Donor type (%)
Living related	-	-	85.7	85.1
Living unrelated	-	-	14.3	11.7
Deceased	-	-	0.0	3.2

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[1] Correspondence to: Moisés Carminatti. E-mail: moicarminatti@yahoo.com.br