Results of a coordination and shared clinical information programme between primary care and nephrology.

INTRODUCTION: The high prevalence of chronic kidney disease (CKD) in the general population has created a need to coordinate specialised nephrology care and primary care. Although several systems have been developed to coordinate this process, published results are scarce and contradictory. OBJECTIVE: To present the results of the application of a coordinated programme between nephrology care and primary care through consultations and a system of shared clinical information to facilitate communication and improve the criteria for referring patients. METHODS: Elaboration of a coordinated care programme by the primary care management team and the nephrology department, based on the SEN-SEMFYC consensus document and a protocol for the study and management of arterial hypertension (AHT). Explanation and implementation in primary health care units. A directory of specialists' consultations was created, both in-person and via e-mail. A continuous training programme in kidney disease and arterial hypertension was implemented in the in-person consultation sessions. The programme was progressively implemented over a three-year period (2007-2010) in an area of 426,000 inhabitants with 230 general practitioners. Use of a clinical information system named Salut en Xarxa that allows access to clinical reports, diagnoses, prescriptions, test results and clinical progression. RESULTS: Improved referral criteria between primary care and specialised nephrology service. Improved prioritisation of visits. Progressive increase in referrals denied by specialists (28.5% in 2009), accompanied by an explanatory report including suggestions for patient management. Decrease in first nephrology outpatient visits that have been referred from primary care (15% in 2009). Family doctors were generally satisfied with the improvement in communication and the continuous training programme. The main causes for denying referral requests were: patients >70 years with stage 3 CKD (44.15%); patients <70 years with stage 3a CKD (19.15%); albumin/creatinine ratio <500 mg/g (12.23%); non-secondary, non-refractory, essential AHT (11.17%). The general practitioners included in the programme showed great interest and no complaints were registered. CONCLUSIONS: The consultations improve adequacy and prioritisation of nephrology visits, allow for better communication between different levels of the health system, and offer systematic training for general practitioners to improve the management of nephrology patients. This process allows for referring nephrology patients with the most complex profiles to nephrology outpatient clinics.

[Coordinating between the renal transplant unit and the non-transplant nephrology department]. / Coordinación entre Unidad de trasplante renal y Servicio de Nefrología no trasplantador.

Patients with stabilized kidney transplant receive optimal management care when there is effective coordination between the transplant centre and the community nephrologist (Evidence level C). A good coordination with regular interactive communication between the transplant centre and community nephrologist is very positive for patients and beneficial to the transplant centre and community nephrologist (Evidence level C). Many of the clinical objectives for management of kidney transplant recipients are similar to those related to chronic kidney disease patients (Evidence level C). A good coordination between the transplant centre and community nephrologist needs organizational requirements and clinical management protocols (Evidence level C).When irreversible renal allograft failure occurs, the community nephrologist must assume the preparation for dialysis as with other patients with advanced chronic kidney disease: choose dialysis methods, create arteriovenous fistulae or place peritoneal catheter and identify dialysis treatment centre. Moreover, the transplant centre and the community nephrologist will jointly decide the best moment to start dialysis or the possibility of preemptive kidney transplant (Evidence level C).

Coordinación entre unidad de trasplante renal y servicio de nefrología no trasplantador / Coordintating between the renal transplant unit and the non-transplant nephrology department

El paciente con trasplante renal estabilizado recibe un manejo clínico óptimo del sistema sanitario cuando se coordinan las Unidades de trasplante renal (UTR) con los Servicios de Nefrología del hospital de referencia (nivel de evidencia C). La buena coordinación entre las UTR y los Servicios de Nefrología del hospital de referencia supone ventajas para el paciente y tiene interés para el Servicio de Nefrología y la UTR (nivel de evidencia C). Muchos de los objetivos clínicos del paciente trasplantado renal son similares a los del paciente con insuficiencia renal crónica (IRC) controlado en los Servicios de Nefrología de los hospitales de referencia (nivel de evidencia C). La buena coordinación entre la UTR y el Servicio de Nefrología precisa requerimientos organizativos y protocolización del manejo clínico compartido (nivel de evidencia C). Cuando comienza a desarrollarse el fracaso irreversible del injerto renal, el Servicio de Nefrología del hospital de referencia debe ofrecer la preparación para la diálisis como al resto de pacientes con IRC avanzada: elección de la técnica de diálisis, realización de fístula arteriovenosa o catéter peritoneal según el caso, e identificación del centro de tratamiento. Asimismo, habrá que decidir conjuntamente con la UTR el mejor momento para empezar la diálisis o, incluso, si el paciente se puede beneficiar de un trasplante renal anticipado que hiciera innecesario el ingreso en diálisis (nivel de evidencia C) (AU)

Patients with stabilized kidney transplant receive optimal management care when there is effective coordination between the transplant centre and the community nephrologist (Evidence level C). A good coordination with regular interactive communication between the transplant centre and community nephrologist is very positive for patients and beneficial to the transplant centre and community nephrologist (Evidence level C). Many of the clinical objectives for management of kidney transplant recipients are similar to those related to chronic kidney disease patients (Evidence level C). A good coordination between the transplant centre and community nephrologist needs organizational requirements and clinical management protocols (Evidence level C). When irreversible renal allograft failure occurs, the community nephrologist must assume the preparation for dialysis as with other patients with advanced chronic kidney disease: choose dialysis methods, create arteriovenous fistulae or place peritoneal catheter and identify dialysis treatment centre. Moreover, the transplant centre and the community nephrologist will jointly decide the best moment to start dialysis or the possibility of preemptive kidney transplant (Evidence level C) (AU)

Acidosis láctica fatal por metformina en un paciente con diabetes mellitus tipo 2 y deshidratación. Sugerencias sobre un prospecto farmacéutico / Fatal lactic acidosis in a male with type 2 diabetes mellitus and dehydration. Comments about a patient information leaflet

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