Janet Hegarty

Serum phosphate and mortality in patients with chronic kidney disease

BACKGROUND AND OBJECTIVES Higher phosphate is associated with mortality in dialysis patients but few prospective studies assess this in nondialysis patients managed in an outpatient nephrology clinic. This prospective longitudinal study examined whether phosphate level was associated with death in a referred population. DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS Patients (1203) of nondialysis chronic kidney disease (CKD) in the Chronic Renal Insufficiency Standards Implementation Study were assessed. Survival analyses were performed for quartiles of baseline phosphate relative to GFR, 12-month time-averaged phosphate, and baseline phosphate according to published phosphate targets. RESULTS Mean (SD) eGFR was 32 (15) ml/min per 1.73 m(2), age 64 (14) years, and phosphate 1.2 (0.30) mmol/L. Cox multivariate adjusted regression in CKD stages 3 to 4 patients showed an increased risk of all-cause and cardiovascular mortality in the highest quartile compared with that in the lowest quartile of phosphate. No association was found in CKD stage 5 patients. Patients who had values above recommended targets for phosphate control had increased risk of all-cause and cardiovascular death compared with patients below target. The highest quartile compared with the lowest quartile of 12-month time-averaged phosphate was associated with an increased risk of mortality. CONCLUSIONS In CKD stages 3 to 4 patients, higher phosphate was associated with a stepwise increase in mortality. As phosphate levels below published targets (as opposed to within them) are associated with better survival, guidelines for phosphate in nondialysis CKD patients should be re-examined. Intervention trials are required to determine whether lowering phosphate will improve survival.

The Effects of Statins on the Progression of Atherosclerotic Renovascular Disease

Background/Aims: The aim was to examine the influence of statin therapy on the natural history of atherosclerotic renal artery stenosis (RAS). Methods: Our hospital atherosclerotic renovascular disease (ARVD) database was analysed for patients who underwent repeat renal angiography during clinical follow-up. Patients with ≧1 RAS lesion and ≧4 months between baseline and repeat renal angiography were analysed. 79 patients were included. Baseline renal arterial anatomy was classified as normal, ≤50% RAS, >50% RAS or renal artery occlusion. Results: Mean follow-up time between angiograms was 27.8 ± 22.3 (4.0–101.9) months. Progression of RAS occurred in 28 (23%) vessels, regression in 14 (12%) and no significant change in 79 (65%). Multivariate regression analysis showed that baseline proteinuria >0.6 g/day increased the risk of progressive disease (relative risk, RR, 3.8; 95% confidence interval, CI, 1.2–12.1), treatment with statin reduced the risk of progression (RR 0.28; 95% CI 0.10–0.77). 14 renal arteries from 12 patients showed RAS regression with a greater proportion on statin [statin treatment 10 (83%) versus no statin treatment 2 (17%), p = 0.001]. Change in estimated glomerular filtration rate (eGFR) per year was not different between statin- and no-statin-treated groups. Conclusions: Progression or development of RAS was significantly less likely to occur with statin therapy. ΔeGFR did not correlate with progression of RAS, reflecting the importance of intrarenal injury in the aetiology of renal dysfunction. Our results suggest statin therapy can alter the natural history of ARVD.

A collaborative project to improve identification and management of patients with chronic kidney disease in a primary care setting in Greater Manchester

Problem Research has demonstrated a knowledge and practice gap in the identification and management of chronic kidney disease (CKD). In 2009, published data showed that general practices in Greater Manchester had a low detection rate for CKD. Design A 12-month improvement collaborative, supported by an evidence-informed implementation framework and financial incentives. Setting 19 general practices from four primary care trusts within Greater Manchester. Key measures for improvement Number of recorded patients with CKD on practice registers; percentage of patients on registers achieving nationally agreed blood pressure targets. Strategies for change The collaborative commenced in September 2009 and involved three joint learning sessions, interspersed with practice level rapid improvement cycles, and supported by an implementation team from the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Greater Manchester. Effects of change At baseline, the 19 collaborative practices had 4185 patients on their CKD registers. At final data collection in September 2010, this figure had increased by 1324 to 5509. Blood pressure improved from 34% to 74% of patients on practice registers having a recorded blood pressure within recommended guidelines. Lessons learnt Evidence-based improvement can be implemented in practice for chronic disease management. A collaborative approach has been successful in enabling teams to test and apply changes to identify patients and improve care. The model has proved to be more successful for some practices, suggesting a need to develop more context-sensitive approaches to implementation and actively manage the factors that influence the success of the collaborative.

Understanding the implementation of interventions to improve the management of chronic kidney disease in primary care: a rapid realist review

BackgroundChronic kidney disease (CKD) is common and a significant marker of morbidity and mortality. Its management in primary care is essential for maintenance of cardiovascular health, avoidance of acute kidney injury (AKI) and delay in progression to end-stage renal disease. Although many guidelines and interventions have been established, there is global evidence of an implementation gap, including variable identification rates and low patient communication and awareness. The objective of this study is to understand the factors enabling and constraining the implementation of CKD interventions in primary care.MethodsA rapid realist review was conducted that involved a primary literature search of three databases to identify existing CKD interventions in primary care between the years 2000 and 2014. A secondary search was performed as an iterative process and included bibliographic and grey literature searches of reference lists, authors and research groups. A systematic approach to data extraction using Normalisation Process Theory (NPT) illuminated key mechanisms and contextual factors that affected implementation.ResultsOur primary search returned 710 articles that were narrowed down to 18 relevant CKD interventions in primary care. Our findings suggested that effective management of resources (encompassing many types) was a significant contextual factor enabling or constraining the functioning of mechanisms. Three key intervention features were identified from the many that contributed to successful implementation. Firstly, it was important to frame CKD interventions appropriately, such as within the context of cardiovascular health and diabetes. This enabled buy-in and facilitated an understanding of the significance of CKD and the need for intervention. Secondly, interventions that were compatible with existing practices or patients’ everyday lives were readily accepted. In contrast, new systems that could not be integrated were abandoned as they were viewed as inconvenient, generating more work. Thirdly, ownership of the feedback process allowed users to make individualised improvements to the intervention to suit their needs.ConclusionsOur rapid realist review identified mechanisms that need to be considered in order to optimise the implementation of interventions to improve the management of CKD in primary care. Further research into the factors that enable prolonged sustainability and cost-effectiveness is required for efficient resource utilisation.

Factors associated with vascular stiffness: Cross-sectional analysis from the chronic renal insufficiency standards implementation study

Background: Vascular stiffness is associated with increased cardiovascular risk. This study aimed to identify factors associated with vascular stiffness in a cohort of chronic kidney disease (CKD) patients. Methods: The Chronic Renal Insufficiency Standards Implementation Study is a prospective epidemiological study of CKD patients not on dialysis, who are managed in a clinic setting. Phenotypic parameters were collected annually, and vascular stiffness was assessed using augmentation index (AI). Cross-sectional analysis was performed across quintiles of AI to evaluate factors associated with vascular stiffness. Results: Mean patient age was 66.1 ± 14.1 years and estimated glomerular filtration rate (eGFR) was 31.2 ± 5.7 ml/min. Corrected calcium was 2.26 ± 0.2 SD mmol/l, phosphate 1.2 ± 0.4 SD mmol/l and intact parathyroid hormone 94 ± 96 SD pg/ml; 18.3% of patients had cardiovascular disease. Increased age and systolic blood pressure were associated with increased AI (all p < 0.001). No statistical association was present between AI and eGFR, intact parathyroid hormone, phosphate or protein excretion. Conclusion: This study identified blood pressure as a potentially modifiable risk factor associated with AI, whereas eGFR was not associated with increased AI in a population of CKD stage 3–5 patients. Further knowledge of factors which influence progression of vascular stiffness will be important in risk quantification and management.

Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative

Quality problem Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD. Initial assessment Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼30% were estimated to have suboptimal management according to Public Health Observatory analyses. Choice of solution An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices. Implementation A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement. Evaluation Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved. Lessons learned An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention.

Effect of a Quality Improvement Program to Improve Guideline Adherence and Attainment of Clinical Standards in Dialysis Care: Report of Outcomes in Year 1

Background: Best practice in dialysis is synthesised in clear international guidelines. However, a large gap remains between the international guidelines and the actual delivery of care. In this paper, we report outcomes for the first year of a multifaceted dialysis improvement programme in our network. Methods: One year collaborative involving 3 haemodialysis units and a peritoneal dialysis (PD) programme involving 299 dialysis patients. Each unit addressed a different indicator (unit A - catheter-related bloodstream infection [CRBSI], unit B - pre-dialysis blood pressure [BP], unit C - dialysis dose, unit D - anaemia) with a shared aim to match the top 10% in the UK. Tailored multifaceted approaches include a modified collaborative methodology with an aim, framework, driver diagram, learning sessions, facilitated meetings, plan-do-study-act cycles and continuous measurement. Analysis of outcomes, costings, erythropoietin stimulating agent and iron use, and safety culture attributes. Results: Unit A reduced CRBSI from 2.65 to 0.5 per 1,000 catheter days (p = 0.02). Unit B improved attainment of target BP from 37.5 to 67.2% (p = 0.003). Unit C improved attainment of target urea reduction ratio from 75.8 to 91.4% (p = 0.04). PD unit D improved attainment of target haemoglobin from 45.5 to 62.7% (p = 0.01), with no significant change in the indicators in a non-intervention unit. Safety culture attributes improved. Costs associated with admission for fluid overload and infection, erythropoietin, iron and thrombokinase use decreased 36% (£415,620-£264,143). Conclusions: Units that took part in this collaborative improved guideline adherence compared both to their own pre-intervention performance and a non-intervention unit. Such multifaceted interventions are a useful methodology to improve dialysis care.

Effect of renal artery revascularization upon cardiac structure and function in atherosclerotic renal artery stenosis: cardiac magnetic resonance sub-study of the ASTRAL trial

Background Cardiac abnormalities are frequent in patients with atherosclerotic renovascular disease (ARVD). The Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial studied the effect of percutaneous renal revascularization combined with medical therapy compared with medical therapy alone in 806 patients with ARVD. Methods This was a pre-specified sub-study of ASTRAL (clinical trials registration, current controlled trials number: ISRCTN59586944), designed to consider the effect of percutaneous renal artery angioplasty and stenting on change in cardiac structure and function, measured using cardiac magnetic resonance (CMR) imaging. Fifty-one patients were recruited from six selected ASTRAL centres. Forty-four completed the study (medical therapy n = 21; revascularization n = 23). Full analysis of CMR was possible in 40 patients (18 medical therapy and 22 revascularization). CMR measurements of left and right ventricular end systolic (LV and RVESV) and diastolic volume (LV and RVEDV), ejection fraction (LVEF) and mass (LVM) were made shortly after recruitment and before revascularization in the interventional group, and again after 12 months. Reporting was performed by CMR analysts blinded to randomization arm. Results Groups were well matched for mean age (70 versus 72 years), blood pressure (148/71 versus 143/74 mmHg), degree of renal artery stenosis (75 versus 75%) and comorbid conditions. In both randomized groups, improvements in cardiac structural parameters were seen at 12 months, but there were no significant differences between treatment groups. Median left ventricular changes between baseline and 12 months (medical versus revascularization) were LVEDV -1.9 versus -5.8 mL, P = 0.4; LVESV -2.1 versus 0.3 mL, P = 0.7; LVM -5.4 versus -6.3 g, P = 0.8; and LVEF -1.5 versus -0.8%, P = 0.7. Multivariate regression also found that randomized treatment assignment was not associated with degree of change in any of the CMR measurements. Conclusions In this sub-study of the ASTRAL trial, renal revascularization did not offer additional benefit to cardiac structure or function in unselected patients with ARVD.

Improving CKD Diagnosis and Blood Pressure Control in Primary Care: A Tailored Multifaceted Quality Improvement Programme

Background: Chronic kidney disease (CKD) is a worldwide public health issue. From 2009 to 2014, the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care Greater Manchester (NIHR CLAHRC GM) in England ran 4 phased, 12-month quality improvement (QI) projects with 49 primary care practices in GM. Two measureable aims were set – halve undiagnosed CKD in participating practices using modelled estimates of prevalence; and optimise blood pressure (BP) control (<140/90 mm Hg in CKD patients without proteinuria; <130/80 mm Hg in CKD patients with proteinuria) for 75% of recorded cases of CKD. The 4 projects ran as follows: P1 = Project 1 with 19 practices (September 2009 to September 2010), P2 = Project 2 with 11 practices (March 2011 to March 2012), P3 = Project 3 with 12 practices (September 2012 to October 2013), and P4 = Project 4 with 7 practices (April 2013 to March 2014). Methods: Multifaceted intervention approaches were tailored based on a contextual analysis of practice support needs. Data were collected from practices by facilitators at baseline and again at project close, with self-reported data regularly requested from practices throughout the projects. Results: Halving undiagnosed CKD as per aim was exceeded in 3 of the 4 projects. The optimising BP aim was met in 2 projects. Total CKD cases after the programme increased by 2,347 (27%) from baseline to 10,968 in a total adult population (aged ≥18 years) of 231,568. The percentage of patients who managed to appropriate BP targets increased from 34 to 74% (P1), from 60 to 83% (P2), from 68 to 71% (P3), and from 63 to 76% (P4). In nonproteinuric CKD patients, 88, 90, 89, and 91%, respectively, achieved a target BP of <140/90 mm Hg. In proteinuric CKD patients, 69, 46, 48, and 45%, respectively, achieved a tighter target of <130/80 mm Hg. Analysis of national data over similar timeframes indicated that practices participating in the programme achieved higher CKD detection rates. Conclusions: Participating practices identified large numbers of “missing” CKD patients with comparator data showing they outperformed non-QI practices locally and nationally over similar timeframes. Improved BP control also occurred through this intervention, but overall achievement of the tighter BP target in proteinuric patients was notably less.

PP20 Improved Identification of Chronic Kidney Disease Cases in Primary Care

Background Undiagnosed chronic kidney disease (CKD) leads to a high cost and care burden in secondary care. Current stage 3–5 prevalence is estimated at 6.35%, but recorded prevalence in primary care is often significantly lower. Increasing the prevalence of diagnosed CKD in primary care would allow management and prevention of deterioration, but detection rates for CKD remain low. We developed a primary care quality improvement intervention to help identify and manage CKD patients. Methods A 2x12-month improvement project using financial incentives and structured facilitation was carried out in 30 general practices in Greater Manchester. Practices were helped to identify improvement objectives tailored to their context, (such as validating and updating practice registers) and were monitored by the improvement team. In the first 12 months, practices were provided with in-depth facilitation by knowledge transfer associates. The second phase was less resource-intensive; seconding a clinical facilitator, developing a change package, replacing collaborative meetings with fewer web seminars, and introduction of a CKD audit tool. Key indicators of change were: number of recorded patients with CKD on practice registers: percentage of patients on registers achieving nationally recognised blood pressure targets. Data were collected by practice staff. Practices also received a readiness to change questionnaire to assess practice culture and flexibility. Results Baseline prevalence across the practices was 4.2%. By the end of the project, recorded prevalence reached 5.4%. Practice registers recorded an increase of 22% of patients with CKD, indicating improved identification of cases. Overall, 2042 patients were added to registers, although taking miscoded patients into account the true number of newly identified patients is likely to be higher. Management of patients also improved from 38% managed to blood pressure target at baseline increasing to 64%. Wide variation amongst practices was accounted for by readiness to change. The two-stage project allowed learning, knowledge and skills to be developed in phase 1, which could then be streamlined and put into practice in phase 2. Discussion The quality improvement project was associated with a 22% increase in identification of CKD patients, and a 170% increase in patients managed to NICE recommended blood pressure targets. These represent a potential huge saving for the NHS in estimated avoided vascular events. Clinical facilitation and use of a structured audit tool were associated with accelerated and sustained improvement in case finding, building on an earlier phase of experimentation and relationship-building.