A chart that plots eGFR with age may be a useful clinical tool to assist GPs in the optimal management of patients with declining renal function, an Australian study has found.
A case vignette study, published in the British Journal of General Practice (BJGP) Open [link here], found having access to the chart led to more appropriate management of cases.
In the study 373 GPs were randomised to receive two case vignettes either with the kidney age trajectory chart (immediate chart group) or without the chart (delayed chart group), and were asked a series of questions about how they would manage the cases.
GPs who did not receive the chart immediately were subsequently given the chart and asked the same questions a second time.
The cases were a 76-year old woman with stable but reduced kidney function in the CKD stage 3a category and a 45-year old First Nations man with an eGFR in the normal range but decreased by 5 mL/min/1.73 m2 in the previous 12 months. Both were overweight with slightly elevated blood pressure (140/90 mmHg) but otherwise well.
In the case of the older woman, the study found GPs with immediate access to the kidney age trajectory chart were more comfortable with longer intervals between reviews than GPs with delayed access to the chart.
Similarly, use of the chart was associated with longer time until repeat pathology testing and reduced use of lipid-lowering medication.
“Before seeing the chart, the vast majority would not refer to a nephrologist (97%). However, after receiving the chart, an additional small minority (4%) of GPs would consider referring to a nephrologist for advice (P = 0.04).”
With the First Nations case, GPs with immediate access to the chart were more likely to choose earlier time intervals for reviews and repeat pathology testing compared with GPs in the delayed access to the chart group.
“GPs in the immediate chart group were more likely to recommend blood pressure reduction for this patient case (P = 0.046), more likely to recommend lifestyle intervention (P = 0.012), and more likely to avoid nephrotoxic medications (P<0.0001) compared with the delayed chart group,” the study said.
“Most GPs would not refer the First Nations man to a nephrologist, but access to the chart was associated with an increase in the proportion of GPs wanting to seek further advice (6% delayed chart vs 16% immediate chart, P = 0.0015).”
“Only with the age comparison chart was it clearly shown that his eGFR might be problematic.”
The investigators, including from Bond University’s Institute for Evidence-Based Healthcare and the Baker Heart and Diabetes Institute, said use of the chart reduced proposals for unnecessary pathology testing and unnecessary early follow-up.
They said age was not considered as a factor in the stages of CKD and current CKD guidelines do not use age as part of the treatment recommendation algorithm.
“However, there is still debate about older people in stage 3a as to how aggressively these patients need to be managed. An individual approach is required with older people, taking into account their comorbidities, functional states, and personal priorities,” they said.
“A kidney trajectory chart can be a useful tool for GPs to help in a discussion with patients about their own functional status, likelihood of further decline in kidney function, and other health priorities.”
They concluded that a trial of the kidney trajectory chart in clinical practice would be useful to see whether it improves the recognition and management of reduced kidney function overall and, in particular, reduces overdiagnosis and concern in older patients.
Current chronic kidney disease guidelines do not take patient age into account. This study shows use of a kidney trajectory chart by GPs has potential to prevent both over- and under-diagnosis, and improve management
➡️https://t.co/v3KsueBwBS@PaulGlasziou @WiserHealthCare pic.twitter.com/f0gVVDMA1Y
— BJGP Open Journal (@BJGPOpen) April 4, 2024