Early Warning Signs of CKD Going Unnoticed in Veterans, Especially Those With Hypertension

The federal government wants to lower the rate of end-stage renal disease (ESRD) and improve kidney care outcomes, but such efforts will require earlier identification of chronic kidney disease (CKD), especially in veterans. At the American Society of Nephrology's (ASN) Kidney Week 2019, one poster described the gaps in identifying CKD in this population.

The veteran population is at higher risk of CKD given their comorbidities, older age, or previous environmental exposures, said Shweta Bansal, MD, of University of Texas Health, in an interview with The American Journal of Managed Care^®. The risk of CKD for veterans is 36%, while the risk for the general population is about 14%, she said.

She and other researchers in Texas examined CKD screening and recognition rate in at-risk veterans enrolled in a veterans’ healthcare service network and evaluated the impact of CKD awareness on care processes. The results showed room for improvement.

Researchers examined data records from the healthcare network for veterans who were seen at least twice in primary care clinics, screening International Classification of Diseases, Ninth Revision, (ICD-9-CM) codes for hypertension and diabetes; those comorbidities have the highest risk for CKD. The final group of 220,229 subjects (55.6% hypertension, 6% diabetes and 38.4% both) was examined for tests for serum creatinine/ estimated glomerular filtration rate (eGFR), a measure of kidney function.

Presence of CKD was defined as eGFR <60ml/min at least twice 90 days apart and/or urine albumin creatinine ratio (uACR) of >30 mg/g. Blood pressure readings from last 2 visits were averaged to evaluate hypertension control. In addition, prescription rates for statins and nonsteroidal anti-inflammatory agents (NSAIDs) were assessed.

Overall, 173,966 (79%) patients had 1 or other screening procedures performed.

However, patients with isolated hypertension were less likely to have any screening procedure (72.8%) as compared with diabetes (81.1%), or both hypertension and diabetes (87.6%).

Only 40.3% of total patients had urine protein recorded in their charts, compared with diabetes (62.6%) or both hypertension and diabetes (68.5%). The percentage was much lower for patients who only had hypertension (18.3%).

While 42.5% of the 173,966 patients had lab evidence of CKD, only 19,317 (26.1%) had a documented ICD-9 CKD diagnosis.

Many of these unrecognized CKD patients (30.5%) had CKD based on uACR criteria.

There was no clinically significant difference between recognized vs unrecognized CKD groups in terms of age, sex and race; blood pressure control and the statin prescription rate were also similar.

Diuretics prescription was higher (66.7% vs 58%) and NSAIDs was lower (11.4% vs. 22.9%) in documented vs undocumented CKD groups.

Notably, patients with blood pressure >140/90 mmHg consistently had high rates of uACR >300 mg/g irrespective of CKD documentation.

By and large, patients with hypertension did not get their proteinuria measured. “That was the biggest lag,” said Bansal.

“We were surprised to see that only 26% of the patients who had evidence of CKD had the diagnostic code in the chart, which is a marker of PCP awareness,” she said.

The implications about care are concerning, Bansal said.

“Unless you know that patients have CKD, you’re not going to be aggressive with their blood pressure control, with their sugar control, having them on ACEI/ARB [angiotensin converting enzyme inhibitors/angiotensin-receptor blockers] inhibitors, avoiding the nephrotoxins,” she said.

“You cannot recognize [ESRD] at stage 4 and avoid going on to 5," Bansal said, pointing out that diagnosing and treating earlier can stabilize the disease earlier and prevent the slide into ESRD by controlling blood sugar, blood pressure, implementing lifestyle changes, and, she said, the use of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide- agonists.

"The problem is, if you don’t even know the patient has CKD, what’s the use of those medications? You need to give those medicines early on," she said.

The Department of Veterans Affairs (VA) cares for more than 600,000 veterans with kidney disease in their 153 medical treatment facilities or 800 community-based outreach clinics.

Reference

Bansal S, Mader MJ. Screening and recognition of primary care clinics in the VA health care system and its impact on the delivery of care. Presented at: American Society of Nephrology Kidney Week 2019, Washington, DC; November 5-10, 2019. Poster PO869.