Removing the Barriers for CKD Management

This week in BMC Nephrology, an article by Neale et al. evaluated the barriers and enablers to the detection of chronic kidney disease (CKD) in the primary healthcare setting. In this BMC Nephrology World Kidney Day blog, Blog Editor Dr. Daphne Harrington Knicely examines the benefits of early CKD detection and management and how we can enhance efforts in primary healthcare for early CKD diagnosis.

Chronic kidney disease (CKD) affects 850 million people worldwide.  This global health burden continues to increase each year.  There are no symptoms in early CKD.  It is not until CKD has progressed to the point of needing dialysis that patients develop recognizable symptoms.  This means that it is vital that patients are screened for CKD, since early diagnosis can prevent the progression of kidney disease.  World Kidney Day on 12th March 2020 will focus on “Kidney Health for Everyone Everywhere – from Prevention to Detection and Equitable Access to Care”.  Primary care providers (PCPs) are on the frontline against CKD progression by making the early diagnosis.

A systematic review by Neale et al., published today in BMC Nephrology, evaluated the barriers and enablers to the diagnosis and management of CKD in primary care.  Most reviews focus on barriers or enablers but this article was able to address both, which go hand-in-hand in helping PCPs tackle the growing health burden of CKD.  Twenty studies were included in the review. The most common barriers identified were lack of time, fear of delivering the CKD diagnosis, and dissatisfaction with CKD guidelines.  The most common enablers were the presence of supportive technology to identify and manage CKD and collaborative relationships among members of the healthcare team. These and some other identified barriers and enablers from Neale et al. are listed in table 1.

Table 1: Management and Detection of CKD in Primary Healthcare.  The most common are highlighted orange. 

Strategies to Enhance Early Detection and Management

Healthcare professionals frequently complain of the inadequate amount of time they can spend with patients. However, PCPs have one of the highest workloads, managing preventative care, acute complaints, multiple co-morbidities, etc.  Developing strategies to streamline the identification and management of CKD through electronic medical records and increasing the use of calculators for estimated GFR and kidney failure risk would benefit PCPs.  In addition, adopting policies that enable longer consultations for complex patients will allow protected time to deal with the management of chronic diseases like CKD.

Effective co-management of patients with CKD between PCPs and nephrologists is recognized as a key strategy to deliver high-quality CKD care.

Improving CKD knowledge and confidence in diagnosis will empower PCPs to provide early diagnosis.  If patients know they have CKD in the primary care setting, they can take steps to increase their own CKD knowledge and self-management of CKD, promoting future favorable outcomes. One study implemented a toolkit to enhance awareness of CKD among PCPs.  This quality improvement activity led to greater identification of CKD, increased referral to nephrology, increased communication among PCPs and nephrologists, and the development of co-management plans. Toolkits like this one should be used more frequently for providing continuing education and resources for our PCPs.

Guidelines rarely deal with comorbidities, but practice guidelines that consider the co-morbid nature of CKD would increase understanding and use among PCPs.  It will help with prioritizing the patient’s problem list and management strategies.  One potential solution is to develop guidelines that consider common clusters of chronic conditions. ERBP, KDIGO and KDOQI have already started to address this by providing guidelines on CKD and co-morbidities such as diabetes mellitus, hepatitis C, and cardiovascular disease.

Effective co-management of patients with CKD between PCPs and nephrologists is recognized as a key strategy to deliver high-quality CKD care.  Interventions facilitating the exchange of information, clear delineation of roles/responsibilities, and greater access to specialist advice improve the co-management of patients with CKD.

PCPs and nephrologists working together in a multi-disciplinary team to care of these complex patients can only lead to future healthcare benefits.


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