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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA-AFRICA  
Year : 2011  |  Volume : 22  |  Issue : 6  |  Page : 1285-1288
Preliminary audit on early identification and management of chronic kidney disease in adults in an acute general medical unit in Sri Lanka


1 Sri Lanka Medical Association-Diabetes Prevention Task Force, Sri Lanka
2 Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka
3 Kings Mill Hospital, Sherwood Forest NHS Foundation Trust, Sutton-in-Ashfield, Notts, United Kingdom

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Date of Web Publication8-Nov-2011
 

   Abstract 

This was the first round of an audit to analyze how closely the National Institute of Clinical Excellence (NICE) guidelines on early identification and management of chronic kidney disease in adults is adhered to by a medical ward in the National Hospital of Sri Lanka. One hundred consecutive patients who were not diagnosed to have chronic kidney disease (CKD) but had risk factors for future development of CKD were selected from the male and female wards of the University Medical Unit, National Hospital, Colombo, Sri Lanka. Data were collected by interviewing patients and from the case notes, and entered on a proforma designed based on the recommendations outlined in the NICE guidelines on the prevention of CKD. Target blood pressure was achieved in 66% (n=66). Urine ward test was performed only in 58% of the patients, and this was positive for protein in 15 patients. Investigations to exclude urinary tract infection were performed in 12%. Measurement of serum creatinine was carried out in 40%, but estimated glomerular filtration rate, albumin:creatinine ratio and protein:creatinine ratio were not carried out in any of the patients. Forty percent of the patients were educated by ward staff regarding CKD, 22% on risk factor modification, 23% regarding renal replacement therapy, 34% regarding dietary modifications and 67% regarding importance of exercise. Twenty-six percent of the patients were not educated on any of the above components. ACEI, ARB and statins were prescribed only in 47%, 9% and 64%, respectively. Although follow-up was indicated in all these patients, it was arranged only in 17%. The concurrence with NICE guidelines on CKD prevention was found to be poor. Strategies for improvement are discussed.

How to cite this article:
De Silva S, Weerasinghe D, Rajapakse A, Maithripala C, Rajapakse S. Preliminary audit on early identification and management of chronic kidney disease in adults in an acute general medical unit in Sri Lanka. Saudi J Kidney Dis Transpl 2011;22:1285-8

How to cite this URL:
De Silva S, Weerasinghe D, Rajapakse A, Maithripala C, Rajapakse S. Preliminary audit on early identification and management of chronic kidney disease in adults in an acute general medical unit in Sri Lanka. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Nov 13];22:1285-8. Available from: http://www.sjkdt.org/text.asp?2011/22/6/1285/87257

   Introduction Top


Chronic kidney disease (CKD) results in significant morbidity and mortality, and places a considerable burden on health care resources. Late referral of advanced kidney disease to nephrology services from primary and secondary care is still as high as 30%, engendering increased mortality and morbidity. [1] Early identification of renal disease, with subsequent referral to a nephrologist, is known to improve outcome. In Sri Lanka, where facilities for longterm hemodialysis or renal transplantation are very limited, and also incurs high cost to patients, prevention of CKD is of paramount importance. Data from the Sri Lanka Annual Health Bulletin 2006 reports 150,593 patients admitted to hospital classified as having diseases of the urinary system, with 1551 deaths (disease coding did not specify the exact nature of the disease, although chronic renal disease was included in this). The importance of early identification and prevention of kidney disease in high-risk patients has been emphasized as a priority area by the National Service Framework for Renal Services of the UK, [2] and in September 2008, the National Institute of Clinical Excellence (NICE) published guidelines on early identification of CKD in adults in primary and secondary care. [3]

In Sri Lanka, there are currently no standard guidelines in force for the screening or prevention of CKD. The NICE guidelines are available to practicing clinicians in Sri Lanka, and are used in the absence of local guidelines. The prevalence of renal risk factors, in particular hypertension and diabetes mellitus, is high, and, in addition, there is a considerable burden of CKD in certain parts of the country of which the etiology is unknown.

We conducted this preliminary audit to determine to what degree clinical practice in a tertiary care general medical unit in Colombo, Sri Lanka, is in concurrence with the recommendations of the NICE guidelines on early detection and prevention of CKD. The audit was conducted in the University Medical Unit of the National Hospital, Colombo, Sri Lanka, which is a tertiary care acute general medical unit. Our aim was to identify deficiencies in clinical practice with regards to concurrence with the said NICE guidelines, with a view to implementing strategies to improve compliance with the guidelines, which could then be extrapolated for use in other general medical units in the hospital and in the country.


   Methods Top


We studied 100 consecutive patients with identified risk factors for the development of CKD, admitted to the University Medical Unit, National Hospital, Colombo, over a period of two months from August 2009. Data was collected using a proforma designed based on the recommendations of the NICE guidelines, and was obtained by interviewing patients and reviewing patient's case notes. Ethics clearance was obtained from the Ethics Review Committee, National Hospital, Colombo.

Audit measures, based on the NICE guidelines, [2] were defined as follows:
  • Target blood pressure achieved (target blood pressures were defined as follows: in normal healthy patients, the target blood pressure was 140/90 mmHg; in diabetic patients with ACR >70, the target was 125/75 mmHg; and in others with risk factors, the target was 130/80 mmHg)
  • Re-evaluation of the serum creatinine/estimated glomerular filtration rate (e-GFR) within a week when routine e-GFR was below 60 mLs/min/1.73m 2 ; evaluation of recent reductions in eGFR; [in patients with an e-GFR below 60 mL/min, expected standards of care included determining the rate of reduction of GFR, and in cases where there was a reduction of eGFR of more than 15% since the last value was seen, evaluation for possible precipitant causes (urinary symptoms, palpable bladder, blood pressure changes, heart failure, recent addition of ACE inhibitors, angiotensin receptor blockers, NSAIDs, antibiotics, and ultrasonic evaluation to exclude obstructive uropathy)]
  • Urine albumin to creatinine ratio (ACR)/or protein creatinine ratio (PCR) performed when proteinuria was present (significant proteinuria was considered as +1 or more on dipstick testing); exclusion of infection by urine-analysis
  • Referral to nephrologist where indicated; plans for follow-up (renal referral was considered necessary in the following instances: GFR as below 30 mL/min, progressive drop in GFR >5 mL/min per year, PCR >45 with microscopic hematuria, PCR >100, suspected systemic illness like systemic lupus erythematosis (SLE), refractory hypertension (blood pressure >150/90 with 4 anti-hypertensive medications), anemia with a hemoglobin of <11 g/L with no other cause or persistent abnormal potassium, calcium or phosphates)
  • Urology referrals done for males over 50 years with hematuria (significant hematuria was considered as +1 or more on dipstick urine examination)

   Results Top


One hundred patients were studied. There were 66 males and 34 females. The pattern of renal risk factors in the cohort is shown in [Figure 1].
Figure 1: Pattern of risk factors for chronic kidney disease. IHD - ischemic heart disease, HT - hypertension, DM-1 - Type I diabetes mellitus, DM-2 - Type II diabetes mellitus, CCF - congestive cardiac failure, PVD - peripheral vascular disease, SLE - systemic lupus erythematosus.

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Target blood pressure was achieved in 66% (n=66). Urine dipstick testing for albumin was not available in the wards due to lack of resources and, instead, the heat coagulation test for proteins was used. The test was performed only in 58% of the patients, and was found to be positive for protein in 15 patients. Investigations to exclude urinary tract infection were performed in 12%. Measurement of serum creatinine was carried out in 40%, but eGFR calculation was not performed. ACR and PCR were not carried out in any of the patients. Forty percent of the patients were educated by ward staff regarding CKD, 22% on risk factor modification, 23% regarding the need for renal replacement therapy in case of developing endstage renal failure, 34% regarding dietary modifications and 67% regarding importance of exercise. No education of any sort was provided to 26% of the patients. ACEI, ARB and statins were prescribed only in 47%, 9% and 64%, respectively. Although follow-up was indicated in all these patients, it was arranged only in 17%.


   Discussion Top


Overall, clinical practice in the unit did not compare favorably with the recommendations of the NICE guidelines. Clearly, one of the key limitations was the non-availability of certain basic investigations such as random urinary PCR ratio estimation. Nonetheless, control of hypertension was clearly sub-optimal. We interviewed the doctors to identify reasons for the shortcomings; lack of time for patient education, due to the heavy workload, was one of the reasons expressed by the doctors for the poor performance with regards to patient education. It was also identified that despite the easy availability and accessibility to the NICE guidelines, awareness of the guidelines was found to be poor.

The following interventions are likely to improve strategies toward the prevention of CKD:

  1. Education of doctors regarding the NICE guidelines, and provision of the guidelines to clinicians;
  2. Implementation of a checklist/pathway for routine implementation to all patients with risk factors for CKD. We intend to implement this in our unit, and re-audit in three months;
  3. More effective control of blood pressure by ensuring that appropriate dose modifications are made to achieve target blood pressure. The use of reno-protective drugs in high-risk populations must be emphasized.
It is unlikely that current healthcare resource provisions will permit routine estimation of ACR/PCR. However, making available urine dipstick testing will certainly allow for more accurate and sensitive detection of proteinuria. Local pathways will necessarily have to adapt to available resources.

This preliminary audit reinforces an important fact - simple, yet effective, strategies for prevention of CKD are often ignored. Most of the strategies that would prevent CKD are relatively simple to implement and require doctor-education and adherence to protocols rather than sophisticated investigations or medications.

 
   References Top

1.Arora P, Obrador GT, Ruthazer R, et al. Prevalence, predictors and consequences of late nephrology referral at a tertiary care center. J Am Soc Nephrol 1999;10:1281-6.  Back to cited text no. 1
    
2.Department of Health National Service Framework for renal services - part Two: Chronic Kidney disease, acute renal failure and end of life care. London: UK: Department of Health 2005  Back to cited text no. 2
    
3.NICE guideline September 2008 Early identification and management of chronic kidney disease in adults in primary and secondary care.  Back to cited text no. 3
    

Top
Correspondence Address:
Senaka Rajapakse
Consultant Physician and Professor, Department of Clinical Medicine, Faculty of Medicine University of Colombo
Sri Lanka
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PMID: 22089805

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