Chronic kidney disease (CKD) affects approximately 13% of adults and is associated with significant morbidity, mortality and financial burden. The National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI) practice guidelines for CKD management delineate recommendations pertaining to diagnosis, stemming progression, treating complications and indications for referral to nephrology. However, several studies have shown that there is limited knowledge and application of KDOQI guidelines among both primary care providers and nephrologists. Efforts to improve guideline adherence have been limited. There have been a paucity of initiatives to improve the delivery of CKD care, and there is a need for innovative solutions to CKD management that impact outcomes such as CKD progression and mortality. We seek to determine adherence to KDOQI guidelines for CKD, and assess the impact of CKD guideline adherence on mortality and CKD progression. We also seek to study the impact of implementing a CKD checklist designed for primary care providers, incorporating CKD management recommendations, on guideline adherence. We propose a retrospective cohort study of 1172 patients with stages 1-4 CKD over a one year time period (2009) to determine adherence to KDOQI guidelines for CKD management. In addition, we piloted a prospective cohort study over a one year time period (2012-2013) with a CKD checklist intervention group and a control group not involving the CKD checklist intervention in an outpatient internal medicine clinic, and we propose examining the impact of this intervention on adherence to CKD management guidelines. For both studies we will collect CKD adherence process measures such as blood pressure recordings, urine protein studies, HbA1c measurements, use of ACE-I/ARBs, LDL measurement, use of statins, smoking cessation counseling, counseling regarding avoidance of nephrotoxic agents, measurement of anemia and bone mineral testing, and administration of vaccinations. For the retrospective cohort study we will also obtain outcome measures such as blood pressure control, proteinuria control, prescription of NSAIDs, LDL <100, hemoglobin within target range, bone mineral disease management within target range, eGFR and mortality. We will stratify our cohort into two subpopulations based on their rate of adherence relative to the median and compare outcomes between these two groups. For the prospective cohort study we will compare adherence patterns between patients who did and did not receive the checklist intervention.

Public Health Relevance

Chronic kidney disease (CKD) is a condition associated with significant morbidity, mortality and financial burden, and affects approximately 13% of the US adult population. Optimal CKD care involves multiple components: diagnosis, treatment of comorbid conditions, slowing progression, cardiovascular risk reduction, estimating progression, evaluating and treating complications, and preparation for renal replacement therapy. Examining adherence to guidelines and interventions to improve adherence may result in improved CKD management and potentially reduce associated morbidity and mortality.

National Institute of Health (NIH)
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Postdoctoral Individual National Research Service Award (F32)
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Special Emphasis Panel (ZDK1)
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Rankin, Tracy L
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Brigham and Women's Hospital
United States
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Mendu, Mallika L; Lundquist, Andrew; Aizer, Ayal A et al. (2015) The usefulness of diagnostic testing in the initial evaluation of chronic kidney disease. JAMA Intern Med 175:853-6
Mendu, Mallika L; Schneider, Louise I; Aizer, Ayal A et al. (2014) Implementation of a CKD checklist for primary care providers. Clin J Am Soc Nephrol 9:1526-35