Abstract
Background
The adverse effects arising from late referral to a nephrologist of patients with chronic kidney disease (CKD) are well known. Retrospectively we examined the initial characteristics of patients referred in various stages of CKD to our nephrology division and tried to identify potential baseline factors associated with subsequent changes in estimated glomerular filtration rate (eGFR).
Patients and methods
Between September 1997 and June 2006 1,443 patients (909 male, 534 female) with CKD, with eGFRs ranging from 15 to 89 ml/min, were referred to our nephrology division and categorized using the National Kidney Foundation classification for CKD based on eGFR. The slope of eGFR change (ml/min−1/1.73/m2−1/year−1) was determined by linear regression analysis and the patients were divided into five groups: (1) significantly progressive slope (deterioration) (more negative than −5 ml/min/year); (2) mildly progressive slope (>−5 to ≤−1); (3) stable slope (>−1 to ≤+1); (4) mildly improved slope (>+1 to ≤+5), and (5) significantly improved slope (≥+5).
Results
At the first nephrology referral, 5.8% of the patients were on CKD stage 2 (eGFR: 90–60 ml/m), 46.7% on CKD stage 3 (eGFR: 59–30 ml/m), and 47.5% on CKD stage 4 (eGFR: 29–15 ml/m) CKD. Significantly improved slope was detected in 48.2% of CKD stage 2 patients, 29.3% of CKD stage 3 patients, and only 14.7% of CKD stage 4 patients (P < 0.05). Being in stage 4 or stage 3 versus being in stage 2 significantly reduced the likelihood of an improved slope in logistic regression analysis whereas age, gender, presence of hypertension, and diabetes mellitus did not reach the level of significance.
Conclusion
Referral to a nephrology clinic can lead not only to arrest of progression of CKD but also to regression/improvement. Early referral is a positive predictive factor for improvement in eGFR, which emphasizes the importance of such referral. The previously held idea that, once established, CKD progresses invariably is not valid anymore.
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References
Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS (2003) Prevalence of chronic kidney disease and decreased kidney function in the adult US population: third national health and nutrition examination survey. Am J Kidney Dis 41:1–12
Ruggenenti P, Schieppati A, Remuzzi G (2001) Progression, remission, regression of chronic renal diseases. Lancet 357:1601–1608
Levin A (2001) Identification of patients, risk factors in chronic kidney disease-evaluating risk factors and therapeutic strategies. Nephrol Dial Transplant 16(suppl 7):57–60
Lindeman RD (2007) Hypertension and kidney protection in the elderly: what is the evidence in 2007. Int Urol Nephrol 39(2):669–678
Silverberg DS, Wexler D, Iaina A, Steinbruch S, Wollman Y, Schwartz D (2006) Anemia, chronic renal disease and congestive heart failure—the cardio renal anemia syndrome: the need for cooperation between cardiologists and nephrologists. Int Urol Nephrol 38(2):295–310
Arora P, Mustafa RA, Karam J, Khalil P, Wilding G, Ranjan R, Lohr J (2006) Care of elderly patients with chronic kidney disease. Int Urol Nephrol 38(2):363–367
K/DOQI clinical practice guidelines for chronic kidney disease (2002) Kidney disease outcomes quality initiative. Am J Kidney Dis 39(suppl 2):1–266
Arora P, Obrador GT, Ruthazer R et al (1999) Prevalence, predictors, and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol 10:1281–1286
Jungers P, Zingraff J, Albouze G, Chauveau P, Page B, Hannedouche T et al (1993) Late referral to maintenance dialysis: detrimental consequences. Nephrol Dial Transplant 8:1089–1093
Lameire N, Van Biesen W (1999) The pattern of referral of patients with end-stage renal disease to the nephrologist—a European survey. Nephrol Dial Transplant 14(S6):16–23
Innes A, Rowe PA, Burden RP, Morgan AG (1992) Early deaths on renal replacement therapy: the need for early nephrological referral. Nephrol Dial Transplant 7:467–471
Khan IH, Catto GR, Edward N, MacLeod AM (1995) Death during the first 90 days of dialysis: a case control study. Am J Kidney Dis 25:276–280
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D (1999) A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of diet in renal disease study group. Ann Intern Med 130:461–470
Jones C, Roderick P, Harris S, Rogerson M (2006) Decline in kidney function before, after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease. Nephrol Dial Transplant 21(8):2133–2143
Fioretto P, Steffes MW, Sutherland DE, Goetz FC, Mauer M (1998) Reversal of lesions of diabetic nephropathy after pancreas transplantation. N Engl J Med 339:69–75
Ando Y, Moriyama T, Oka K, Takatsuji K, Miyazaki M, Akagi Y et al (1999) Enhanced interstitial expression of caldesmon in IgA nephropathy and its suppression by glucocorticoid-heparin therapy. Nephrol Dial Transplant 14:1408–1417
Benigni A, Zoja C, Corna D, Orisio S, Facchinetti D, Benati L et al (1996) Blocking both type A and B endothelin receptors in the kidney attenuates renal injury and prolongs survival in rats with remnant kidney. Am J Kidney Dis 27:416–423
Adamczak M, Gross ML, Krtil J, Koch A, Tyralla K, Amann K et al (2003) Reversal of glomerulosclerosis after high-dose enalapril treatment in subtotally nephrectomized rats. J Am Soc Nephrol 14:2833–2842
Remuzzi A, Gagliardini E, Donadoni C, Fassi A, Sangalli F, Lepre MS et al (2002) Effect of angiotensin II antagonism on the regression of kidney disease in the rat. Kidney Int 62:885–894
Liu Y (2004) Hepatocyte growth factor in kidney fibrosis: therapeutic potential, mechanisms of action. Am J Physiol Renal Physiol 287:F7–F16
Marinides GN, Groggel GC, Cohen AH, Border WA (1990) Enalapril and low protein reverse chronic puromycin aminonucleoside nephropathy. Kidney Int 37:749–757
Ruggenenti P, Perna A, Cherardi G, gaspari F, Benini R, Remuzzi G (1998) Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in Nephropathy. Lancet 352:1252–1256
Ruggenenti P, Perna A, Benini R, Bertani T, Zoccali C, Maggiore Q et al (1999) In chronic nephropathies prolonged ACE inhibition can induce remission: dynamics of time-dependent changes in GFR. Investigators of the GISEN Group. Gruppo Italiano Studi Epidemiologici in Nefrologia. J Am Soc Nephrol 10:997–1006
Wilmer WA, Hebert LA, Lewis EJ, Rohde RD, Whittier F, Cattran D et al (1999) Remission of nephrotic syndrome in type 1 diabetes: long-term follow-up of patients in the Captopril Study. Am J Kidney Dis 34:308–314
Feest TG, Dunn EJ, Burton CJ (1999) Can intensive treatment alter the progress of established diabetic nephropathy to end-stage renal failure? QJM 92(5):275–282
Hunsicker LG, Adler S, Caggiula A, England Bk, Greene T, Kusek JW et al (1997) Predictors of the progression of renal disease in the modification of diet in renal disease study. Kidney Int 51:1908–1919
Eriksen BO, Ingebretsen OC (2006) The progression of chronic kidney disease: a 10-year population-based study of the effects of gender and age. Kidney Int 69(2):375–382
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Taskapan, H., Tam, P., Au, V. et al. Improvement in eGFR in patients with chronic kidney disease attending a nephrology clinic. Int Urol Nephrol 40, 841–848 (2008). https://doi.org/10.1007/s11255-008-9360-9
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DOI: https://doi.org/10.1007/s11255-008-9360-9