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Risk of ESRD and death in patients with CKD not referred to a nephrologist: a
7-year prospective study
#MMPMID25074838
Minutolo R
; Lapi F
; Chiodini P
; Simonetti M
; Bianchini E
; Pecchioli S
; Cricelli I
; Cricelli C
; Piccinocchi G
; Conte G
; De Nicola L
Clin J Am Soc Nephrol
2014[Sep]; 9
(9
): 1586-93
PMID25074838
show ga
BACKGROUND AND OBJECTIVES: Rising prevalence of CKD requires active involvement
of general practitioners to limit ESRD and mortality risk. However, the outcomes
of patients with CKD exclusively managed by general practitioners are ill
defined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We prospectively
evaluated 30,326 adult patients with nondialysis CKD stages 1-5 who had never
received consultation in tertiary nephrology care recruited from 700 general
practitioner offices in Italy during 2002 and 2003. CKD stages were classified as
stages 1 and 2 (GFR ? 60 ml/min per 1.73 m(2) and either albuminuria or an
International Classification of Diseases, Ninth Revision, Clinical Modification
code for kidney disease), stage 3a (GFR=59-45), stage 3b (GFR=44-30), stage 4
(GFR=29-15), and stage 5 (GFR<15). Primary outcome was the risk of ESRD (dialysis
or transplantation) or all-cause death. RESULTS: Overall 64% of patients were in
stage 3a, and 4.5% of patients were in stages 3b-5. Patients with stages 1 and 2
were younger, were predominantly men, more frequently had diabetes, and had lower
prevalence of previous cardiovascular disease than patients with stages 3a-5.
Hypertension was frequent in all CKD stages (80%-94%), whereas there was a lower
prevalence of dyslipidemia, albuminuria, and obesity associated with more
advanced CKD. During the follow-up (median=7.2 years; interquartile
range=4.7-7.7), 6592 patients died and 295 started ESRD. Compared with stages 1
and 2 (reference), mortality risk (hazard ratio, 95% confidence interval) was
higher in stages 3b-5 (1.66, 1.49-1.86, 2.75, 2.41-3.13 and 2.54, 2.01-3.22,
respectively) but not stage 3a (1.11, 0.99-1.23). Similarly, ESRD risk (hazard
ratio, 95% confidence interval) was not higher at stage 3a (1.44, 0.79-2.64) but
was greater in stages 3b-5 (11.0, 6.3-19.5, 91.2, 53.2-156.2 and, 122.8,
67.9-222.0, respectively). Among modifiable risk factors, anemia and albuminuria
significantly predicted either outcome, whereas hypertension only predicted
mortality. CONCLUSIONS: In patients with CKD not referred to nephrology, risks of
ESRD and mortality were higher in those with CKD stages 3b-5.
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