Original Investigation
Pathogenesis and Treatment of Kidney Disease and Hypertension
An Evaluation of a Shared Primary and Secondary Care Nephrology Service for Managing Patients With Moderate to Advanced CKD

https://doi.org/10.1053/j.ajkd.2005.09.020Get rights and content

Background: Chronic kidney disease (CKD) is common, and nephrology services may not cope with the comprehensive referral of patients with CKD. We evaluated a shared primary and secondary care nephrology scheme, hypothesizing that some patients with less progressive moderate to advanced CKD can be identified and safely managed without attending the renal unit. Methods: A retrospective review of 949 new referrals with stages 3 to 5 CKD managed in either the hospital nephrology clinic (HC) or the shared care scheme (SCS), in which nephrologists review patients remotely by using regular biochemical tests and clinical data recorded in primary care. Results: Two hundred sixty-six patients (28%) were enrolled in the SCS and 683 patients (72%) were managed solely in the HC. Median time to entering the SCS was 111 days (interquartile range, 0 to 328 days). Baseline factors independently predictive of enrollment in the SCS were increasing age, greater glomerular filtration rate (GFR) and serum albumin levels, and no diabetic nephropathy. Few SCS patients did not attend reviews. Forty-one patients (15%) required recall to the HC, mostly because of a decline in GFR. Beneficial changes were seen in blood pressure levels and prescribing of angiotensin-system inhibitors from first referral to 3 years in all patients. Those enrolled in the SCS had good prognosis, with a lower risk for death or renal replacement therapy than the HC group after adjustment for age, sex, GFR, diabetic nephropathy, and vascular disease (hazard ratio, 0.64; 95% confidence interval, 0.38 to 0.89; P = 0.003). Conclusion: In this setting, it was possible to select nearly 30% of patients with stages 3 to 5 CKD for management in the SCS. More than half enrolled within 4 months of nephrology referral. Systematic surveillance was effective, and most patients remained stable, with few progressing to renal replacement therapy or death.

Section snippets

The SIMON Programme

The SIMON Programme started in 1993 and provides specialist nephrology care for the population of the former Southampton and South West Hampshire Health Authority, a mixed urban/rural area of the United Kingdom with a catchment population of approximately 400,000. In addition to managing patients in the HC, the SIMON Programme has a shared primary and nephrology care scheme (SCS; Fig 1). In this scheme, patients considered by nephrologists to be stable and uncomplicated are enrolled in the SCS,

Baseline Characteristics

At referral, patients were elderly (median age, 75 years) and 61% were men (Table 1). Vascular disease and diabetic nephropathy were present in 42% and 16% of patients, respectively. Relatively few patients in all groups met UK Renal Association guidelines for systolic (<140 mm Hg) and diastolic (<80 mm Hg) blood pressure at referral.

Two hundred sixty-six of 949 new referrals (28%) were enrolled in the SCS, 154 (58%) within 6 months (SCS <6 months) and 112 (42%) after 6 months of first

Discussion

In this retrospective review of a single nephrology center, nearly 30% of patients with moderate to advanced CKD and better prognostic factors were selected for enrollment in an SCS. They were managed successfully without face-to-face contact with nephrologists despite almost one third having advanced renal disease. More than half of those enrolled in the SCS did so within 4 months of first presentation to nephrology services, and although other patients (SCS >6 months) required a median of 18

Acknowledgment

The authors thank the British Renal Society for providing a research grant to fund this work; Dr Rodney Dathan for advice about the SCS; Natasha Wilson, the SIMON database manager, for invaluable assistance with this review; and the editors and anonymous reviewers for their helpful comments.

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    Originally published online as doi:10.1053/j.ajkd.2005.09.020 on November 18, 2005.

    Support: British Renal Society project grant. Potential conflicts of interest: None.

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