Delay the progression of chronic kidney disease from multiple discipline team care: Taiwan experience_West China Medical Journal

Authors：

WU Ping-Hsun ^1,2 ,  CHEN Hung-Chun ^1,2,3

1. Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan 80708, P. R. China;
2. College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan 80708, P. R. China;
3. Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan 80708, P. R. China;

Corresponding author：

CHEN Hung-Chun, Email: chenhc@kmu.edu.tw

Keywords：

Chronic kidney disease; Renal function; Proteinuria; Multidisciplinary team

DOI：

10.7507/1002-0179.201905212

Video：

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The prevalence, incidence, and medical expenses of end-stage renal disease (ESRD) is extremely high in Taiwan, China; so decreasing the incidence of ESRD is a major work for kidney disease prevention in Taiwan, China. Current chronic kidney disease (CKD) guideline suggests multidisciplinary team (MDT) care for CKD patient with estimated glomerular filtration rate (eGFR) less than 30 mL/(min·1.73 m²). MDT includes not only nephrologist but also nursing specialty, dietitian, social worker, psychologist, and other professional personnel. The aim of the MDT care is to preserve renal function, decrease complications, provide nutrient support and nephrotoxic drug consultation, establish the concept of renal replacement therapy and preparation for dialysis access, provide the renal transplantation information, and give the psychosocial support. These cares should provide to CKD patients one year before starting renal replacement therapy. The MDT care for CKD could delay the progression from CKD to ESRD, lower the mortality and hospitalization of CKD, slow the renal function decline, provide better medical care and quality of life for patients, and decrease the medical expenditures. Besides, advanced CKD patients receiving MDT care have higher arteriovenous access preparation rate that prevent the additional intervention and hospitalization while starting dialysis. MDT care also decreases the hospitalization costs and medical expenditures, and decrease 3-year mortality rate after dialysis initiation. The further developing MDT care includes: (1) providing personalized renal care and treatment model, and intergraded care by cardiology-nephrology-diabetes-neurology model; (2) new iCKD care with health management platform and care mode combined with communication technology; (3) shared decision making for choice of renal replacement therapy; (4) advance care planning clinic for palliative treatment of ESRD. All MDT care hopes to establish a person-oriented care policy, provides a better quality care model, not only for the patient’s personalized medical care, but also hopes to improve the overall kidney disease care and prevention work. In addition, we can extend the CKD prevention and treatment experience to other countries worldwide.

Citation： WU Ping-Hsun, CHEN Hung-Chun. Delay the progression of chronic kidney disease from multiple discipline team care: Taiwan experience. West China Medical Journal, 2019, 34(7): 727-735. doi: 10.7507/1002-0179.201905212 Copy

1.	Wen CP, Cheng TY, Tsai MK, et al. All-cause mortality attributable to chronic kidney disease: a prospective cohort study based on 462 293 adults in Taiwan. Lancet, 2008, 371(9631): 2173-2182.
2.	Baer G, Lameire N, Van Biesen W. Late referral of patients with end-stage renal disease: an in-depth review and suggestions for further actions. NDT Plus, 2010, 3(1): 17-27.
3.	Luxton G, CARI. The CARI guidelines. Timing of referral of chronic kidney disease patients to nephrology services (adult). Nephrology (Carlton), 2010, 15(Suppl 1): S2-S11.
4.	Jungers P, Zingraff J, Albouze G, et al. Late referral to maintenance dialysis - detrimental consequences. Nephrol Dial Transplant, 1993, 8(10): 1089-1093.
5.	Sesso R, Belasco AG. Late diagnosis of chronic renal failure and mortality on maintenance dialysis. Nephrol Dial Transplant, 1996, 11(12): 2417-2420.
6.	Jungers P, Joly D, Nguyen-Khoa T, et al. Continued late referral of patients with chronic kidney disease. Causes, consequences, and approaches to improvement. Presse Med, 2006, 35(1 Pt 1): 17-22.
7.	Levinsky NG. Specialist evaluation in chronic kidney disease: too little, too late. Ann Intern Med, 2002, 137(6): 542-543.
8.	Hayashi T, Kimura T, Yasuda K, et al. Early nephrology referral 6 months before dialysis initiation can reduce early death but does not improve long-term cardiovascular outcome on dialysis. Circ J, 2016, 80(4): 1008-1016.
9.	Chan MR, Dall AT, Fletcher KE, et al. Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis. Am J Med, 2007, 120(12): 1063-1070.
10.	Nakamura S, Nakata H, Yoshihara F, et al. Effect of early nephrology referral on the initiation of hemodialysis and survival in patients with chronic kidney disease and cardiovascular diseases. Circ J, 2007, 71(4): 511-516.
11.	Chow KM, Szeto CC, Law MC, et al. Impact of early nephrology referral on mortality and hospitalization in peritoneal dialysis patients. Perit Dial Int, 2008, 28(4): 371-376.
12.	Inaguma D, Ando R, Ikeda M, et al. Nephrologist care for 12 months or more increases hemodialysis initiation with permanent vascular access. Clin Exp Nephrol, 2011, 15(5): 738-744.
13.	Hasegawa T, Bragg-Gresham JL, Yamazaki SA, et al. Greater first-year survival on hemodialysis in facilities in which patients are provided earlier and more frequent pre-nephrology visits. Clin J Am Soc Nephrol, 2009, 4(3): 595-602.
14.	Smart NA, Dieberg G, Ladhani M, et al. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease. Cochrane Database Syst Rev, 2014(6): CD007333.
15.	Chen SC, Hwang SJ, Tsai JC, et al. Early nephrology referral is associated with prolonged survival in hemodialysis patients even after exclusion of lead-time bias. Am J Med Sci, 2010, 339(2): 123-126.
16.	Wu MS, Lin CL, Chang CT, et al. Improvement in clinical outcome by early nephrology referral in type II diabetics on maintenance peritoneal dialysis. Perit Dial Int, 2003, 23(1): 39-45.
17.	Chen SC, Chang JM, Chou MC, et al. Slowing renal function decline in chronic kidney disease patients after nephrology referral. Nephrology (Carlton), 2008, 13(8): 730-736.
18.	Lin CL, Wu MS, Hsu PY, et al. Improvement of clinical outcome by early nephrology referral in type II diabetics on hemodialysis. Ren Fail, 2003, 25(3): 455-464.
19.	Buck J, Baker R, Cannaby AM, et al. Why do patients known to renal services still undergo urgent dialysis initiation? A cross-sectional survey. Nephrol Dial Transplant, 2007, 22(11): 3240-3245.
20.	Chen SH, Tsai YF, Sun CY, et al. The impact of self-management support on the progression of chronic kidney disease-a prospective randomized controlled trial. Nephrol Dial Transplant, 2011, 26(11): 3560-3566.
21.	Chen YR, Yang Y, Wang SC, et al. Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study. Nephrol Dial Transplant, 2013, 28(3): 671-682.
22.	Wu IW, Wang SY, Hsu KH, et al. Multidisciplinary predialysis education decreases the incidence of dialysis and reduces mortality-a controlled cohort study based on the NKF/DOQI guidelines. Nephrol Dial Transplant, 2009, 24(11): 3426-3433.
23.	Wei SY, Chang YY, Mau LW, et al. Chronic kidney disease care program improves quality of pre-end-stage renal disease care and reduces medical costs. Nephrology (Carlton), 2010, 15(1): 108-115.
24.	Chan JC, So WY, Yeung CY, et al. Effects of structured versus usual care on renal endpoint in type 2 diabetes: the SURE study a randomized multicenter translational study. Diabetes Care, 2009, 32(6): 977-982.
25.	Hsieh MC, Hsieh YT, Cho TJ, et al. Remission of diabetic nephropathy in type 2 diabetic Asian population: role of tight glucose and blood pressure control. Eur J Clin Invest, 2011, 41(8): 870-878.
26.	Huang MC, Hsu CC, Wang HS, et al. Prospective randomized controlled trial to evaluate effectiveness of registered dietitian-led diabetes management on glycemic and diet control in a primary care setting in Taiwan. Diabetes Care, 2010, 33(2): 233-239.
27.	Gaede P, Lund-Andersen H, Parving HH, et al. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med, 2008, 358(6): 580-591.
28.	Gaede P, Vedel P, Parving HH, et al. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet, 1999, 353(9153): 617-622.
29.	Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med, 2003, 348(5): 383-393.
30.	Chen PM, Lai TS, Chen PY, et al. Multidisciplinary care program for advanced chronic kidney disease: reduces renal replacement and medical costs. Am J Med, 2015, 128(1): 68-76.
31.	Chen YR, Yang Y, Wang SC, et al. Multidisciplinary care improves clinical outcome and reduces medical costs for pre-end-stage renal disease in Taiwan. Nephrology (Carlton), 2014, 19(11): 699-707.
32.	Yu YJ, Wu IW, Huang CY, et al. Multidisciplinary predialysis education reduced the inpatient and total medical costs of the first 6 months of dialysis in incident hemodialysis patients. PLoS One, 2014, 9(11): e112820.
33.	Lin MY, Cheng LJ, Chiu YW, et al. Effect of National pre-ESRD care program on expenditures and mortality in incident dialysis patients: a population-based study. PLoS One, 2018, 13(6): e0198387.
34.	Wu LC, Lin MY, Hsieh CC, et al. Planned creation of vascular access saves medical expenses for incident dialysis patients. Kaohsiung J Med Sci, 2009, 25(10): 521-529.

1. Wen CP, Cheng TY, Tsai MK, et al. All-cause mortality attributable to chronic kidney disease: a prospective cohort study based on 462 293 adults in Taiwan. Lancet, 2008, 371(9631): 2173-2182.
2. Baer G, Lameire N, Van Biesen W. Late referral of patients with end-stage renal disease: an in-depth review and suggestions for further actions. NDT Plus, 2010, 3(1): 17-27.
3. Luxton G, CARI. The CARI guidelines. Timing of referral of chronic kidney disease patients to nephrology services (adult). Nephrology (Carlton), 2010, 15(Suppl 1): S2-S11.
4. Jungers P, Zingraff J, Albouze G, et al. Late referral to maintenance dialysis - detrimental consequences. Nephrol Dial Transplant, 1993, 8(10): 1089-1093.
5. Sesso R, Belasco AG. Late diagnosis of chronic renal failure and mortality on maintenance dialysis. Nephrol Dial Transplant, 1996, 11(12): 2417-2420.
6. Jungers P, Joly D, Nguyen-Khoa T, et al. Continued late referral of patients with chronic kidney disease. Causes, consequences, and approaches to improvement. Presse Med, 2006, 35(1 Pt 1): 17-22.
7. Levinsky NG. Specialist evaluation in chronic kidney disease: too little, too late. Ann Intern Med, 2002, 137(6): 542-543.
8. Hayashi T, Kimura T, Yasuda K, et al. Early nephrology referral 6 months before dialysis initiation can reduce early death but does not improve long-term cardiovascular outcome on dialysis. Circ J, 2016, 80(4): 1008-1016.
9. Chan MR, Dall AT, Fletcher KE, et al. Outcomes in patients with chronic kidney disease referred late to nephrologists: a meta-analysis. Am J Med, 2007, 120(12): 1063-1070.
10. Nakamura S, Nakata H, Yoshihara F, et al. Effect of early nephrology referral on the initiation of hemodialysis and survival in patients with chronic kidney disease and cardiovascular diseases. Circ J, 2007, 71(4): 511-516.
11. Chow KM, Szeto CC, Law MC, et al. Impact of early nephrology referral on mortality and hospitalization in peritoneal dialysis patients. Perit Dial Int, 2008, 28(4): 371-376.
12. Inaguma D, Ando R, Ikeda M, et al. Nephrologist care for 12 months or more increases hemodialysis initiation with permanent vascular access. Clin Exp Nephrol, 2011, 15(5): 738-744.
13. Hasegawa T, Bragg-Gresham JL, Yamazaki SA, et al. Greater first-year survival on hemodialysis in facilities in which patients are provided earlier and more frequent pre-nephrology visits. Clin J Am Soc Nephrol, 2009, 4(3): 595-602.
14. Smart NA, Dieberg G, Ladhani M, et al. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease. Cochrane Database Syst Rev, 2014(6): CD007333.
15. Chen SC, Hwang SJ, Tsai JC, et al. Early nephrology referral is associated with prolonged survival in hemodialysis patients even after exclusion of lead-time bias. Am J Med Sci, 2010, 339(2): 123-126.
16. Wu MS, Lin CL, Chang CT, et al. Improvement in clinical outcome by early nephrology referral in type II diabetics on maintenance peritoneal dialysis. Perit Dial Int, 2003, 23(1): 39-45.
17. Chen SC, Chang JM, Chou MC, et al. Slowing renal function decline in chronic kidney disease patients after nephrology referral. Nephrology (Carlton), 2008, 13(8): 730-736.
18. Lin CL, Wu MS, Hsu PY, et al. Improvement of clinical outcome by early nephrology referral in type II diabetics on hemodialysis. Ren Fail, 2003, 25(3): 455-464.
19. Buck J, Baker R, Cannaby AM, et al. Why do patients known to renal services still undergo urgent dialysis initiation? A cross-sectional survey. Nephrol Dial Transplant, 2007, 22(11): 3240-3245.
20. Chen SH, Tsai YF, Sun CY, et al. The impact of self-management support on the progression of chronic kidney disease-a prospective randomized controlled trial. Nephrol Dial Transplant, 2011, 26(11): 3560-3566.
21. Chen YR, Yang Y, Wang SC, et al. Effectiveness of multidisciplinary care for chronic kidney disease in Taiwan: a 3-year prospective cohort study. Nephrol Dial Transplant, 2013, 28(3): 671-682.
22. Wu IW, Wang SY, Hsu KH, et al. Multidisciplinary predialysis education decreases the incidence of dialysis and reduces mortality-a controlled cohort study based on the NKF/DOQI guidelines. Nephrol Dial Transplant, 2009, 24(11): 3426-3433.
23. Wei SY, Chang YY, Mau LW, et al. Chronic kidney disease care program improves quality of pre-end-stage renal disease care and reduces medical costs. Nephrology (Carlton), 2010, 15(1): 108-115.
24. Chan JC, So WY, Yeung CY, et al. Effects of structured versus usual care on renal endpoint in type 2 diabetes: the SURE study a randomized multicenter translational study. Diabetes Care, 2009, 32(6): 977-982.
25. Hsieh MC, Hsieh YT, Cho TJ, et al. Remission of diabetic nephropathy in type 2 diabetic Asian population: role of tight glucose and blood pressure control. Eur J Clin Invest, 2011, 41(8): 870-878.
26. Huang MC, Hsu CC, Wang HS, et al. Prospective randomized controlled trial to evaluate effectiveness of registered dietitian-led diabetes management on glycemic and diet control in a primary care setting in Taiwan. Diabetes Care, 2010, 33(2): 233-239.
27. Gaede P, Lund-Andersen H, Parving HH, et al. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med, 2008, 358(6): 580-591.
28. Gaede P, Vedel P, Parving HH, et al. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet, 1999, 353(9153): 617-622.
29. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med, 2003, 348(5): 383-393.
30. Chen PM, Lai TS, Chen PY, et al. Multidisciplinary care program for advanced chronic kidney disease: reduces renal replacement and medical costs. Am J Med, 2015, 128(1): 68-76.
31. Chen YR, Yang Y, Wang SC, et al. Multidisciplinary care improves clinical outcome and reduces medical costs for pre-end-stage renal disease in Taiwan. Nephrology (Carlton), 2014, 19(11): 699-707.
32. Yu YJ, Wu IW, Huang CY, et al. Multidisciplinary predialysis education reduced the inpatient and total medical costs of the first 6 months of dialysis in incident hemodialysis patients. PLoS One, 2014, 9(11): e112820.
33. Lin MY, Cheng LJ, Chiu YW, et al. Effect of National pre-ESRD care program on expenditures and mortality in incident dialysis patients: a population-based study. PLoS One, 2018, 13(6): e0198387.
34. Wu LC, Lin MY, Hsieh CC, et al. Planned creation of vascular access saves medical expenses for incident dialysis patients. Kaohsiung J Med Sci, 2009, 25(10): 521-529.

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