Impact of prior CKD management in a renal care network on early outcomes in incident dialysis patients: a prospective observational study.

BACKGROUND: Effective therapeutic strategies are available to prevent adverse outcomes in patients with chronic kidney disease (CKD) but their clinical results are hindered by unplanned implementation. Coordination of care emerges as a suitable way to improve patient outcomes. In this study, we evaluated the effect of planned and coordinated patient management within a dedicated renal care network comparatively to standard renal care delivered in nephrology departments of teaching hospitals. METHODS: This observational matched cohort study included 40 patients with CKD stage 4-5 in the network group as compared with a control group of 120 patients matched for age, sex and diabetic status. Main outcome was a composite endpoint of death from cardiovascular cause and cardiovascular events during the first year after dialysis initiation. RESULTS: There was no difference between the two groups neither for the primary outcome (40% vs 41%) nor for the occurrence of death from cardiovascular cause or cardiovascular events. Whereas the proportion of patients requiring at least one hospitalization was identical (83.3% vs 75%), network patients experienced less individual hospitalizations than control patients (2.3 ± 2.0 vs 1.6 ± 1.7) during the year before dialysis start. Patients of the network group had a slower renal function decline (7.7 ± 2.5 vs 4.9 ± 1.1 ml/min/1,73 m(2) per year; p=0.04). CONCLUSIONS: In this limited series of patients, we were unable to demonstrate a significant impact of the coordinated renal care provided in the network on early cardiovascular events in incident dialysis patients. However, during the predialysis period, there were less hospitalizations and a slower slope of renal function decrease.

[Role of health networks in the screening and management of chronic kidney disease]. / Rôle des réseaux de santé dans le dépistage et la prise en charge de la maladie rénale chronique.

Chronic kidney disease is a public health problem in terms of both the number of patients treated with dialysis or transplantation and the cost of renal replacement therapies, and the excess cardiovascular risk associated with it even at earliest stages. The population of people with chronic renal insufficiency (defined by a glomerular filtration rate<60 mL/min) and therefore exposed to the risk of progression towards end-stage renal failure and excess cardiovascular risk includes roughly 5% of the general population. There are currently effective treatments to slow the progression of chronic kidney disease, delay or avoid dialysis, and prevent cardiovascular events. These treatments are most effective when begun earliest and when followed by professionals aware of the risk factors and the intermediate efficacy criteria: blood pressure, proteinuria, diet, anemia, etc. (Anaes, 2004). Screening for chronic kidney disease is currently facilitated by the routine estimate of creatinine clearance with Cockcroft's formula at every serum creatinine assay (Anaes, 2002). Nephrologists play an essential role when kidney disease is discovered, for it is they who must recognize diseases related to specific treatments and thus to define the long-term risk prevention strategy. Chronic kidney disease develops over years, during which time the patient will see a variety of different healthcare professionals. The transmission of medical information between them is a prerequisite for the continuity of nephroprotective treatment, the prevention of avoidable causes of aggravation (drugs, contrast products, etc.), and the quality of preparation for substitution treatment and transplantation. Because of late referral to nephrologists and insufficient information, an elevated proportion (about 40%) of patients start dialysis in emergency conditions, which reduces their chance of maintaining their independence and using a home-based dialysis method. The system of health networks should provide responses particularly appropriate to the needs of patients with chronic kidney disease. In particular, these networks promote continued medical education, consistent and thorough patient information, and evaluation of practices (HAS, 2006).

[Physical activity and chronic kidney disease: an update in 2013?]. / Activité physique et maladie rénale chronique : quelles relations en 2013 ?

The practice of physical activity is now a subject of special attention in public health. Indeed, the expected benefits in terms of cardiovascular morbidity and mortality suggest that all physicians should promote it. However, there are few data on the impact of physical activity on the health of patients with chronic kidney disease before the dialysis stage. This review focuses on the relationship between chronic kidney disease and the practice of physical activity. Different tools to assess the level of physical activity helped to highlight a marked deterioration in physical capacity of patients with chronic kidney disease, including during the earliest stages. Although there is currently no specific recommendations regarding the practice of physical activity in patients with renal impairment, it seems desirable to promote it in an appropriate way, based on what is currently advocated for cardiovascular prevention in the general population.

[Reluctance of patients with chronic kidney disease stage 3 to join education programs offered by a health network]. / Freins à la participation des patients en stade 3 de la maladie rénale chronique à l'éducation thérapeutique proposée en réseau de santé

INTRODUCTION: Therapeutic education helps patients to acquire the knowledge and ability to live with their disease. However, some patients are not willing to take part in a health education program. Identifying the barriers of their non-adherence would help us to determine accurately their effective educational needs and to adapt the program to deliver a better education for less-motivated patients. PATIENTS AND METHODS: An education program for chronic kidney disease stage 3 patients was implemented across a health network. The study is based on patient's participation during each step of the program. The reasons for non-participation were collected, via direct survey and cross-referencing with available medical records. RESULTS: From 80 eligible patients, and after medical approval, 66 patients received information about the program. Thirty-six patients elected to participate in program and 21 of them joined a therapeutic education group. We did not find any significant differences in the medical or social profile to determine the characteristics of non-participating patients. We found less program involvement however, with patients complying with biomedical follow-up but who do not benefit from complementary paramedical care. CONCLUSION: Nearly half of patients did not take part in the therapeutic education program, primarily those who did not benefit from a multidisciplinary team to manage their chronic disease. Therapeutic education remains a less known concept by patients, and requires an informative and encouraging exhortation from practitioners during casual medical care.

Use of a collaborative database for epidemiological analyses and professional practice evaluation.

RATIONALE: In nephrology, the NEOERICA project assessed the feasibility of the diagnosis scheme based on a general practice database. This approach opened a new area where routinely collected data could be used for purposes other than patient management, such as epidemiological analysis and professional practice evaluation. In Lyon, the TIRCEL network is made up of a coordination team and an online database. In 2008, a total of 468 professionals participated and 983 patients were in the database corresponding to 4114 consultations and 9250 biological assessments. OBJECTIVE: To investigate the impact of a quality control process on the data from operational databases. METHODS: We set up a quality control process and we described the impact of this process on data. We also specifically investigated the role of measurement scales in error frequency and we studied the impact of data quality on variables which could be used for professional practice evaluation. RESULTS: Quality control allowed us to detect as inconsistent data 7.5% of tested data. This rate is linked to the parameters and varied from less than 1% (weight, diastolic blood pressure and urinary sodium) to more than 30% (serum iron and ferritin). Quality control led mainly to the validation of the identified data for 80.4%, a direct correction was realized for 12.9%, 5.6% by the lab and only 1.2% were set to missing. Average proteinuria was modified with the quality control process (2.09 g per 24 hours vs. 0.82 g per 24 hours); however, the median remained stable (0.21 g per 24 hours). CONCLUSION: Specialty databases such as TIRCEL could not be used for epidemiological research or for the extraction of indicators for professional practice evaluation without strict quality control or the set-up of data-entering limits and alarms.

Un enfoque eficaz de la epidemia de enfermedad renal crónica: la red de salud / An effective approach to the epidemic of chronic renal failure: a health network

La red de salud Tircel (multidisciplinaria y que combina la medicina pública y privada), está destinada a pacientescon insuficiencia renal crónica (IRC) de la ciudad de Lyon y comunidades adheridas, de la región Rhone- Alpes, Francia. Su función es coordinar la detección, el tratamiento y la prevención de la progresión de la IRC. Para ello, participa de acciones de formación de profesionales de la salud y de información al público y a los pacientes;también interviene en estudios de investigaciones médicas o socioeconómicas. El historial clínico de todos los pacientes adheridos está computadorizado, y los profesionalesactuantes tienen acceso al mismo a través de Internet. Se presentan en este estudio los resultados, al cabo de 3años de actividad de la misma. Se observó una disminución de la velocidad de progresión de la IRC, una mejorade la presión arterial diastólica y de los niveles de hemoglobina plasmática (estadísticamente significativos),y una tendencia a la disminución de la proteinuria). En el 82% de los pacientes la función renal (FR) (evaluadacomo aclaramiento de creatinina por fórmula de Cockroft y Gault) permaneció estable, en 10% disminuyó y en el 8% mejoró. En los pacientes que tuvieron al menos 4 valores informados de FR, la velocidad de pérdida de lamisma fue de – 3.47 al/min./año en los 6 primeros meses, y de – 0.13 ml/min./año a partir del año de seguimiento (p=0.026). El número de pacientes que recibieron medicamentos con acción sobre el eje renina angiotensina también se incrementó.Estos resultados confirman los efectos beneficiosos que resultan de estar adheridos a una red de salud destinada abrindar tratamiento por IRC.

An effective approach to the epidemic of chronic renal failure: a health network.The health network TIRCEL (multidisciplinary, that combinesprivate and public medicine structures) is directed to patients with chronic kidney disease (CKD); it is locatedin the city of Lyon and adhered communities, of Rhone- Alpes Region, Francia. The net mission is to coordinatethe detection, treatment and prevention of progression of CKD; to fulfill its mission, it is involved in actions directedto improve health professional formation, to inform the patients and the community, and to intervene in medicaland socio-economic research. The clinical data of all the adhered patients is computadorized, and can be accessedby the involved professional through Internet. After three years of running, a reduction in the speed of CKD’s progression, as well as diastolic arterial pressure, and an increase in the levels of plasmatic hemoglobin (allstatistically significant) were observed. Renal function (RF) stayed without modifications in 82% of the patients,deteriorated in 10% and improved in 8%. In patients in whom, al least, 4 determinations of RF, estimated throughCockroft & Gault formula, were done, the deterioration was – 3.47 ml/min/year during the first 6 months, and – 0.13 ml/min/year alter 1 year of follow-up (p=0.026). A tendency to a reduction of proteinuria was observedtoo, as well as an increase in the number of patients that received drugs acting over the renin angiontensin axis.These facts confirmed the benefits obtained through patient’s adhesion to a multidisciplinary health net directedto the treatment of CKD.