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Chronic kidney disease care delivered by US family medicine and internal medicine trainees: results from an online survey.

Lenz O, Fornoni A - BMC Med (2006)

Bottom Line: Questions were focused on the identification of CKD risk factors, screening for CKD and associated co-morbidities, as well as management of anemia and secondary hyperparathyroidism in patients with CKD.Our data show that CKD risk factors are not universally recognized, screening for CKD complications is not generally taken into consideration, and that the management of anemia and secondary hyperparathyroidism poses major diagnostic and therapeutic difficulties for trainees.Educational efforts are needed to raise awareness of clinical practice guidelines and recommendations for patients with CKD among future practitioners.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL, USA. olenz@med.miami.edu

ABSTRACT

Background: Complications of chronic kidney disease (CKD) contribute to morbidity and mortality. Consequently, treatment guidelines have been developed to facilitate early detection and treatment. However, given the high prevalence of CKD, many patients with early CKD are seen by non-nephrologists, who need to be aware of CKD complications, screening methods and treatment goals in order to initiate timely therapy and referral.

Methods: We performed a web-based survey to assess perceptions and practice patterns in CKD care among 376 family medicine and internal medicine trainees in the United States. Questions were focused on the identification of CKD risk factors, screening for CKD and associated co-morbidities, as well as management of anemia and secondary hyperparathyroidism in patients with CKD.

Results: Our data show that CKD risk factors are not universally recognized, screening for CKD complications is not generally taken into consideration, and that the management of anemia and secondary hyperparathyroidism poses major diagnostic and therapeutic difficulties for trainees.

Conclusion: Educational efforts are needed to raise awareness of clinical practice guidelines and recommendations for patients with CKD among future practitioners.

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Related in: MedlinePlus

Blood pressure management in CKD patients. Panel A shows the blood pressure goals chosen for patients with stage 3 CKD. Panel B shows the classes of antihypertensive agents identified as first-line therapy to slow the progression of renal failure in patients with mild to moderate renal impairment. For panels A and B, data were pooled from all respondents as no differences were found between trainees' or attendings' responses. Panel C shows the proportion of respondents who would add an angiotensin converting enzyme inhibitor to the regimen of a hypertensive patient with microalbuminuria currently treated with a thiazide diuretic, as a function of the patient's serum creatinine. ***p < 0.005 for family medicine versus internal medicine trainees and p < 0.05 for family medicine trainees versus attendings. p > 0.05 for internal medicine trainees versus attendings.
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Figure 3: Blood pressure management in CKD patients. Panel A shows the blood pressure goals chosen for patients with stage 3 CKD. Panel B shows the classes of antihypertensive agents identified as first-line therapy to slow the progression of renal failure in patients with mild to moderate renal impairment. For panels A and B, data were pooled from all respondents as no differences were found between trainees' or attendings' responses. Panel C shows the proportion of respondents who would add an angiotensin converting enzyme inhibitor to the regimen of a hypertensive patient with microalbuminuria currently treated with a thiazide diuretic, as a function of the patient's serum creatinine. ***p < 0.005 for family medicine versus internal medicine trainees and p < 0.05 for family medicine trainees versus attendings. p > 0.05 for internal medicine trainees versus attendings.

Mentions: The vast majority of respondents chose a blood pressure goal of less than 130/80 mmHg for a hypothetical patient with CKD and a creatinine clearance of 40 ml/min (Figure 3A). The question posed was: "Which class of antihypertensive medication was considered a first-line agent to slow the progression of kidney disease in a patient with mild to moderate CKD?" (Figure 3B). The responses from family medicine trainees, internal medicine trainees, and attendings were not statistically different for the data shown in Figures 3A,B, and were therefore pooled. Angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) were the first-line medications chosen by 90% and 48% of respondents, respectively, and only 6% chose neither of the two. Respondents were then given a case scenario of a 37-year-old man with hypertension, microalbuminuria, and a blood pressure of 145/95 mmHg, who is only treated with a thiazide diuretic. Asked if they would add an ACEi to this patient's regimen, a decreasing number of respondents opted to do so as the patient's serum creatinine increased (Figure 3C). Family medicine trainees were significantly less likely to choose an ACEi once the serum creatinine was greater than 1.4 mg/dl (P < 0.0001). There was no difference in the response whether the scenario was given for an African-American or a Non-Hispanic Caucasian man (data not shown).


Chronic kidney disease care delivered by US family medicine and internal medicine trainees: results from an online survey.

Lenz O, Fornoni A - BMC Med (2006)

Blood pressure management in CKD patients. Panel A shows the blood pressure goals chosen for patients with stage 3 CKD. Panel B shows the classes of antihypertensive agents identified as first-line therapy to slow the progression of renal failure in patients with mild to moderate renal impairment. For panels A and B, data were pooled from all respondents as no differences were found between trainees' or attendings' responses. Panel C shows the proportion of respondents who would add an angiotensin converting enzyme inhibitor to the regimen of a hypertensive patient with microalbuminuria currently treated with a thiazide diuretic, as a function of the patient's serum creatinine. ***p < 0.005 for family medicine versus internal medicine trainees and p < 0.05 for family medicine trainees versus attendings. p > 0.05 for internal medicine trainees versus attendings.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC1713248&req=5

Figure 3: Blood pressure management in CKD patients. Panel A shows the blood pressure goals chosen for patients with stage 3 CKD. Panel B shows the classes of antihypertensive agents identified as first-line therapy to slow the progression of renal failure in patients with mild to moderate renal impairment. For panels A and B, data were pooled from all respondents as no differences were found between trainees' or attendings' responses. Panel C shows the proportion of respondents who would add an angiotensin converting enzyme inhibitor to the regimen of a hypertensive patient with microalbuminuria currently treated with a thiazide diuretic, as a function of the patient's serum creatinine. ***p < 0.005 for family medicine versus internal medicine trainees and p < 0.05 for family medicine trainees versus attendings. p > 0.05 for internal medicine trainees versus attendings.
Mentions: The vast majority of respondents chose a blood pressure goal of less than 130/80 mmHg for a hypothetical patient with CKD and a creatinine clearance of 40 ml/min (Figure 3A). The question posed was: "Which class of antihypertensive medication was considered a first-line agent to slow the progression of kidney disease in a patient with mild to moderate CKD?" (Figure 3B). The responses from family medicine trainees, internal medicine trainees, and attendings were not statistically different for the data shown in Figures 3A,B, and were therefore pooled. Angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) were the first-line medications chosen by 90% and 48% of respondents, respectively, and only 6% chose neither of the two. Respondents were then given a case scenario of a 37-year-old man with hypertension, microalbuminuria, and a blood pressure of 145/95 mmHg, who is only treated with a thiazide diuretic. Asked if they would add an ACEi to this patient's regimen, a decreasing number of respondents opted to do so as the patient's serum creatinine increased (Figure 3C). Family medicine trainees were significantly less likely to choose an ACEi once the serum creatinine was greater than 1.4 mg/dl (P < 0.0001). There was no difference in the response whether the scenario was given for an African-American or a Non-Hispanic Caucasian man (data not shown).

Bottom Line: Questions were focused on the identification of CKD risk factors, screening for CKD and associated co-morbidities, as well as management of anemia and secondary hyperparathyroidism in patients with CKD.Our data show that CKD risk factors are not universally recognized, screening for CKD complications is not generally taken into consideration, and that the management of anemia and secondary hyperparathyroidism poses major diagnostic and therapeutic difficulties for trainees.Educational efforts are needed to raise awareness of clinical practice guidelines and recommendations for patients with CKD among future practitioners.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL, USA. olenz@med.miami.edu

ABSTRACT

Background: Complications of chronic kidney disease (CKD) contribute to morbidity and mortality. Consequently, treatment guidelines have been developed to facilitate early detection and treatment. However, given the high prevalence of CKD, many patients with early CKD are seen by non-nephrologists, who need to be aware of CKD complications, screening methods and treatment goals in order to initiate timely therapy and referral.

Methods: We performed a web-based survey to assess perceptions and practice patterns in CKD care among 376 family medicine and internal medicine trainees in the United States. Questions were focused on the identification of CKD risk factors, screening for CKD and associated co-morbidities, as well as management of anemia and secondary hyperparathyroidism in patients with CKD.

Results: Our data show that CKD risk factors are not universally recognized, screening for CKD complications is not generally taken into consideration, and that the management of anemia and secondary hyperparathyroidism poses major diagnostic and therapeutic difficulties for trainees.

Conclusion: Educational efforts are needed to raise awareness of clinical practice guidelines and recommendations for patients with CKD among future practitioners.

Show MeSH
Related in: MedlinePlus