Primary Care Physicians Underdiagnose Chronic Kidney Disease in Diabetic Patients

Early diagnosis can reduce cardiovascular events
Value-Based Care in Cardiometabolic Health August 2012, Vol 1, No 2
Wayne Kuznar

Chronic kidney disease (CKD) is significantly underdiagnosed in the population of patients with type 2 diabetes, say investigators from a multisite, observational, cross-sectional study conducted by the National Kidney Foundation, which was presented by lead investigator Lynda Szczech, MD, President of the National Kidney Foundation, New York City, at the 2012 ADA annual meeting.

Dr Szczech and colleagues assessed the prevalence and the proportion of patients with CKD and type 2 diabetes who were treated within the primary care setting. The study, which was conducted at 466 primary care provider sites and included 9307 patients, used a clinician survey, a patient physical examination and medical history, a single patient blood draw to measure estimated glomerular filtration rate (eGFR) and hemoglobin A1c, a urine dipstick to assess protein, an albumin-creatinine ratio, 2 patient quality-of-life questionnaires, and a 15-month patient medical record review.

Early Stages of CKD Not Recognized
Of the 9307 patients, 5036 (54.1%) had stage 1 to stage 5 CKD, based on eGFR and albuminuria; however, only 607 (12.1%) of the patients with CKD had been identified by their physicians as having the disease. Clinicians were more successful in diagnosing more advanced CKD—stages 3 to 5—than stages 1 and 2.

Of the 445 clinicians who enrolled at least 10 patients, 14.3% had a 50% or better likelihood of identifying patients with CKD, and 48.8% had a likelihood of less than 50%. Almost half (47.0%) of the physicians did not identify any of their patients as having CKD.

No differences were noted in the clinicians’ likelihood of identifying CKD based on practice setting, number of years in practice, or number of patients seen weekly.

“More than 26 million Americans already have chronic kidney disease, which represents about 10% to 15% of the US population. Millions more are at risk due to diabetes,” said Dr Szczech, stating that diabetes is the leading cause of kidney disease. She noted, “Early detection and treatment of kidney disease in patients with diabetes can help slow progression, reduce cardiovascular events, and delay time to kidney failure.”

CKD management guidelines are relatively new compared with guidelines for the management of diabetes or hypertension, and unfamiliarity with the guidelines regarding CKD may be a barrier in physicians recognizing the disease, she added.

The data set from this study will be undergoing further analysis. The research will lead to further longitudinal studies to demonstrate that early recognition and treatment of CKD in people with diabetes will improve long-term health outcomes, including cardiovascular outcomes, Dr Szczech pointed out.

A Call to Action
The hope is that the study will be a clarion call to improve recognition of early-stage CKD so that appropriate preventive measures can be adopted as routine clinical practice, said Chester Fox, MD, Professor of Family Medicine, State University of New York at Buffalo, and a member of the study’s steering committee.

These measures include using specific diabetes drugs in individuals with renal impairment, avoiding the use of nonsteroidal anti-inflammatory drugs, and using renoprotective medications such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers.

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Last modified: September 26, 2012
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