Management model of non-dialysis chronic kidney disease patients_West China Medical Journal

Authors：

GAO Bixia ,  ZHANG Luxia

Renal Division, Department of Medicine, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education; Beijing 100034, P. R. China;

Corresponding author：

ZHANG Luxia, Email: Zhanglx@bjmu.edu.cn

Keywords：

Chronic kidney disease; Management; Multidisciplinary care

DOI：

10.7507/1002-0179.201906072

Video：

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With the increasing number of chronic kidney disease (CKD) population globally, establishing an optimal model of CKD care has become an important issue. The major contents of CKD care include patient education, control of CKD risk factors (such as increased blood pressure and glucose), management of CKD complications, and preparation process of renal replacement therapy in pre-dialysis patients. Compared with other non-communicable diseases management, evidence-based evidence related to CKD care is limited. Based on the related studies worldwide, combined with the characteristics of CKD population and previous experiences in China, this paper discusses the management mode of non-dialysis CKD population.

Citation： GAO Bixia, ZHANG Luxia. Management model of non-dialysis chronic kidney disease patients. West China Medical Journal, 2019, 34(7): 736-739. doi: 10.7507/1002-0179.201906072 Copy

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2.	Wouters OJ, O’Donoghue DJ, Ritchie J, et al. Early chronic kidney disease: diagnosis, management and models of care. Nat Rev Nephrol, 2015, 11(8): 491-502.
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4.	National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis, 2002, 39(2 Suppl 1): S1-S266.
5.	James MT, Hemmelgarn BR, Tonelli M. Early recognition and prevention of chronic kidney disease. Lancet, 2010, 375(9722): 1296-1309.
6.	Fink HA, Ishani A, Taylor BC, et al. Screening for, monitoring, and treatment of chronic kidney disease stages 1 to 3: a systematic review for the U. S. preventive services task force and for an American college of physicians clinical practice guideline. Ann Intern Med, 2012, 156(8): 570-581.
7.	Manns B, Hemmelgarn B, Tonelli M, et al. Population based screening for chronic kidney disease: cost effectiveness study. BMJ, 2010, 341: c5869.
8.	Boulware LE, Jaar BG, Tarver-Carr ME, et al. Screening for proteinuria in US adults: a cost-effectiveness analysis. JAMA, 2003, 290(23): 3101-3114.
9.	Palmer AJ, Valentine WJ, Chen R, et al. A health economic analysis of screening and optimal treatment of nephropathy in patients with type 2 diabetes and hypertension in the USA. Nephrol Dial Transplant, 2008, 23(4): 1216-1223.
10.	Komenda P, Ferguson TW, Macdonald K, et al. Cost-effectiveness of primary screening for CKD: a systematic review. Am J Kidney Dis, 2014, 63(5): 789-797.
11.	Ferguson TW, Tangri N, Tan Z, et al. Screening for chronic kidney disease in Canadian indigenous peoples is cost-effective. Kidney Int, 2017, 92(1): 192-200.
12.	Chen N, Hsu CC, Yamagata K, et al. Challenging chronic kidney disease: experience from chronic kidney disease prevention programs in Shanghai, Japan, Taiwan and Australia. Nephrology (Carlton), 2010, 15(Suppl 2): 31-36.
13.	Stevens PE, de Lusignan S, Farmer CK, et al. Engaging primary care in CKD initiatives: the UK experience. Nephrol Dial Transplant, 2012, 27(Suppl 3): iii5-iii11.
14.	Wang Y, Zhang L, Li X, et al. Improvement of awareness, treatment and control of hypertension among chronic kidney disease patients in China from 1999 to 2005. Hypertens Res, 2009, 32(6): 444-449.
15.	Xu Y, Wang L, He J, et al. Prevalence and control of diabetes in Chinese adults. JAMA, 2013, 310(9): 948-959.
16.	Zhang L, Long J, Jiang W, et al. Trends in chronic kidney disease in China. N Engl J Med, 2016, 375(9): 905-906.
17.	Israni RK, Shea JA, Joffe MM, et al. Physician characteristics and knowledge of CKD management. Am J Kidney Dis, 2009, 54(2): 238-247.
18.	Charles RF, Powe NR, Jaar BG, et al. Clinical testing patterns and cost implications of variation in the evaluation of CKD among US physicians. Am J Kidney Dis, 2009, 54(2): 227-237.
19.	Harvey G, Oliver K, Humphreys J, et al. Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative. Int J Qual Health Care, 2015, 27(1): 10-16.
20.	Liao PJ, Lin TY, Wang TC, et al. Long-term and interactive effects of pay-for-performance interventions among diabetic nephropathy patients at the early chronic kidney disease stage. Medicine (Baltimore), 2016, 95(14): e3282.
21.	Jones C, Roderick P, Harris S, et al. An evaluation of a shared primary and secondary care nephrology service for managing patients with moderate to advanced CKD. Am J Kidney Dis, 2006, 47(1): 103-114.
22.	Ricardo AC, Roy JA, Tao K, et al. Influence of nephrologist care on management and outcomes in adults with chronic kidney disease. J Gen Intern Med, 2016, 31(1): 22-29.
23.	KDIGO working group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int suppl, 2013, 3(1): 1-119.
24.	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.
25.	孟立强, 王玉, 张路霞, 等. 中晚期慢性肾脏病患者肾功能进展危险因素—单中心慢性肾脏病专业门诊队列研究. 中华肾脏病杂志, 2011, 27(8): 555-560.
26.	Wang SM, Hsiao LC, Ting IW, et al. Multidisciplinary care in patients with chronic kidney disease: a systematic review and meta-analysis. Eur J Intern Med, 2015, 26(8): 640-645.
27.	Barrett BJ, Garg AX, Goeree R, et al. A nurse-coordinated model of care versus usual care for stage 3/4 chronic kidney disease in the community: a randomized controlled trial. Clin J Am Soc Nephrol, 2011, 6(6): 1241-1247.
28.	Peeters MJ, van Zuilen AD, van den Brand JA, et al. Nurse practitioner care improves renal outcome in patients with CKD. J Am Soc Nephrol, 2014, 25(2): 390-398.
29.	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.
30.	Liu P, Quinn RR, Karim ME, et al. Nephrology consultation and mortality in people with stage 4 chronic kidney disease: a population-based study. CMAJ, 2019, 191(10): E274-E282.
31.	Liu P, Quinn RR, Oliver MJ, et al. Association between duration of predialysis care and mortality after dialysis start. Clin J Am Soc Nephrol, 2018, 13(6): 893-899.

1. Webster AC, Nagler EV, Morton RL, et al. Chronic kidney disease. Lancet, 2017, 389(10075): 1238-1252.
2. Wouters OJ, O’Donoghue DJ, Ritchie J, et al. Early chronic kidney disease: diagnosis, management and models of care. Nat Rev Nephrol, 2015, 11(8): 491-502.
3. Akbari A, Clase CM, Acott P, et al. Canadian society of nephrology commentary on the KDIGO clinical practice guideline for CKD evaluation and management. Am J Kidney Dis, 2015, 65(2): 177-205.
4. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis, 2002, 39(2 Suppl 1): S1-S266.
5. James MT, Hemmelgarn BR, Tonelli M. Early recognition and prevention of chronic kidney disease. Lancet, 2010, 375(9722): 1296-1309.
6. Fink HA, Ishani A, Taylor BC, et al. Screening for, monitoring, and treatment of chronic kidney disease stages 1 to 3: a systematic review for the U. S. preventive services task force and for an American college of physicians clinical practice guideline. Ann Intern Med, 2012, 156(8): 570-581.
7. Manns B, Hemmelgarn B, Tonelli M, et al. Population based screening for chronic kidney disease: cost effectiveness study. BMJ, 2010, 341: c5869.
8. Boulware LE, Jaar BG, Tarver-Carr ME, et al. Screening for proteinuria in US adults: a cost-effectiveness analysis. JAMA, 2003, 290(23): 3101-3114.
9. Palmer AJ, Valentine WJ, Chen R, et al. A health economic analysis of screening and optimal treatment of nephropathy in patients with type 2 diabetes and hypertension in the USA. Nephrol Dial Transplant, 2008, 23(4): 1216-1223.
10. Komenda P, Ferguson TW, Macdonald K, et al. Cost-effectiveness of primary screening for CKD: a systematic review. Am J Kidney Dis, 2014, 63(5): 789-797.
11. Ferguson TW, Tangri N, Tan Z, et al. Screening for chronic kidney disease in Canadian indigenous peoples is cost-effective. Kidney Int, 2017, 92(1): 192-200.
12. Chen N, Hsu CC, Yamagata K, et al. Challenging chronic kidney disease: experience from chronic kidney disease prevention programs in Shanghai, Japan, Taiwan and Australia. Nephrology (Carlton), 2010, 15(Suppl 2): 31-36.
13. Stevens PE, de Lusignan S, Farmer CK, et al. Engaging primary care in CKD initiatives: the UK experience. Nephrol Dial Transplant, 2012, 27(Suppl 3): iii5-iii11.
14. Wang Y, Zhang L, Li X, et al. Improvement of awareness, treatment and control of hypertension among chronic kidney disease patients in China from 1999 to 2005. Hypertens Res, 2009, 32(6): 444-449.
15. Xu Y, Wang L, He J, et al. Prevalence and control of diabetes in Chinese adults. JAMA, 2013, 310(9): 948-959.
16. Zhang L, Long J, Jiang W, et al. Trends in chronic kidney disease in China. N Engl J Med, 2016, 375(9): 905-906.
17. Israni RK, Shea JA, Joffe MM, et al. Physician characteristics and knowledge of CKD management. Am J Kidney Dis, 2009, 54(2): 238-247.
18. Charles RF, Powe NR, Jaar BG, et al. Clinical testing patterns and cost implications of variation in the evaluation of CKD among US physicians. Am J Kidney Dis, 2009, 54(2): 227-237.
19. Harvey G, Oliver K, Humphreys J, et al. Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative. Int J Qual Health Care, 2015, 27(1): 10-16.
20. Liao PJ, Lin TY, Wang TC, et al. Long-term and interactive effects of pay-for-performance interventions among diabetic nephropathy patients at the early chronic kidney disease stage. Medicine (Baltimore), 2016, 95(14): e3282.
21. Jones C, Roderick P, Harris S, et al. An evaluation of a shared primary and secondary care nephrology service for managing patients with moderate to advanced CKD. Am J Kidney Dis, 2006, 47(1): 103-114.
22. Ricardo AC, Roy JA, Tao K, et al. Influence of nephrologist care on management and outcomes in adults with chronic kidney disease. J Gen Intern Med, 2016, 31(1): 22-29.
23. KDIGO working group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int suppl, 2013, 3(1): 1-119.
24. 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.
25. 孟立强, 王玉, 张路霞, 等. 中晚期慢性肾脏病患者肾功能进展危险因素—单中心慢性肾脏病专业门诊队列研究. 中华肾脏病杂志, 2011, 27(8): 555-560.
26. Wang SM, Hsiao LC, Ting IW, et al. Multidisciplinary care in patients with chronic kidney disease: a systematic review and meta-analysis. Eur J Intern Med, 2015, 26(8): 640-645.
27. Barrett BJ, Garg AX, Goeree R, et al. A nurse-coordinated model of care versus usual care for stage 3/4 chronic kidney disease in the community: a randomized controlled trial. Clin J Am Soc Nephrol, 2011, 6(6): 1241-1247.
28. Peeters MJ, van Zuilen AD, van den Brand JA, et al. Nurse practitioner care improves renal outcome in patients with CKD. J Am Soc Nephrol, 2014, 25(2): 390-398.
29. 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.
30. Liu P, Quinn RR, Karim ME, et al. Nephrology consultation and mortality in people with stage 4 chronic kidney disease: a population-based study. CMAJ, 2019, 191(10): E274-E282.
31. Liu P, Quinn RR, Oliver MJ, et al. Association between duration of predialysis care and mortality after dialysis start. Clin J Am Soc Nephrol, 2018, 13(6): 893-899.

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