Prevalence and factors associated with late referral presentation of - - PowerPoint PPT Presentation

Prevalence and factors associated with late referral presentation of CKD patients to nephrologists at KNH renal clinic.

• Dr. D M Killingo

Physician - Narok District Hospital

Background

 Attention to CKD is increasing worldwide, due

to high incidence from:

• aging, hypertension, diabetes and

infectious diseases

• the huge cost of treatment of ESRD1.

 Timing & quality of care before dialysis affects

morbidity and mortality in CKD patients2

1.Lysaght MJ. J Am Soc Nephrol 2002;13:37-40.

• 2. Stack AG. Am J Kidney Dis 2003; 41: 310–318

• Referral/presentation is late when management could

have been improved by earlier contact with renal services3

• Definitions vary btn need for immediate dialysis and

dialysis < 6months after first contact with a nephrologist.4

• NKF: late referral - CKD stage 4&5
• prevalence: 15%-80% worldwide

3..Eadington D.W. Nephrol Dial Transplant 1996; 11: 2124–2126 4.Lameire ,et al. Kidney Int 2002; 61: S27–S34.

Factors contributing to late referral 5

 CKD aetiology  advanced age, M>F, low SES, lack of

dse awareness, denial

 distance , cost, delayed dx, Lack of

specialists.

5.Navaneethan et al BMC Nephrology 2008 9:3

Study Justification

 CKD is a public health problem due to high

incidence and prevalence of patients requiring RRT, with poor outcomes and high cost of care.

 Late referral/presentation is common and

• bviates the opportunity for significant delay
• f disease progression and institution of

proactive strategies to reduce ESRD in the population.

Broad objective

 To determine the prevalence and factors associated with the late

referral presentation of CKD to nephrologists at the KNH renal clinic and the. Specific objectives

• 1. To document socio-demographic and clinical characteristics of

patients at first visit to nephrologists in the KNH renal clinic.

• 2. To determine the proportion of CKD patients presenting late at

referral to nephrologists in the KNH renal clinic.

• 3. To determine the factors associated with late referral/presentation of

CKD patients to nephrologists at the KNH renal clinic.

Methodology

Study design: Cross-sectional descriptive survey. Study site: KNH renal clinic Study population: 97 CKD patients on first referral visit to nephrologists Study period – Sept - Dec 2008



Inclusion criteria

• patients over 18 years at first visit to nephrologist
• signed informed consent

 Exclusion criteria

• Pts already on follow up by nephrologist
• Refusal to consent

RES RESULTS

Base line c har ac te r istic s of the CKD patie nts

Ag e distr ibution

Me an age = 48.01(±15.34) ye ar s Range :18- 88 yr s Pe ak = 50- 55 ye ar s. Male s=52 F e male s=45; M: F = 1.2:1.

80 60 40 20

Age

15 12 9 6 3

Frequency

Mean = 48.01 Std Dev. =15.34

So c io - de mo g r a phic c ha r a c te r istic s

n=97 F a c to r F r e q ue nc y Pe r c e nta g e

Ma r ita l Sta tus

• Sing le
• Ma r

r ie d

• Se p a r

a te d 20 66 11 20.6 68.0 11.3

E duc a tio n

• No ne
• Pr

ima r y

• Se c o nd a r

y

• T

e rtia ry 25 27 27 18 25.8 27.8 27.8 18.6

E mplo ye d

37 38.1

Me dic a l insur a nc e

29 29.9

Re side nc e

35.6 26 16.3 10.6 6.7 2.9 1 1 5 10 15 20 25 30 35 40 Per cent

Central Nairobi Eastern Rift Valley Nyanza Western N/Eastern Coast

Province Majority of the CKD patie nts c ame from c e ntral provinc e followe d by Nairobi.

Clinic al c har ac te r istic s.

Pa tie nts’ c ompla ints a t pr

e se ntation.

Othe r- he a da c he , b o ne pa ins, indig e stio n

General physical examination findings

Patie nts’ Known risk fac tors for CKD at pre se ntation

DM-diabetes mellitus, HTN-hypertension, HIV- human immunodeficiency virus PKD-polycystic kidney disease

76.2% ha d a t le a st o ne kno wn risk fa c to r fo r CK D

38.1 38.1 8.2 6.3 5.2 2.1 5 10 15 20 25 30 35 40 Pe r c e nt

HT N DM HIV PKD Obstruc tive Uropa thy He pa titis B

Known risk for CKD

Dur ation that patie nts had known of the diagnosis of kidne y dise ase [fr

• m the ir

pr

• i. he alth c ar

e pr

• vide r

s].

At pr e se ntation 87.6% of the CKD patie nts had be e n infor me d that the y had a Kidne y dise ase . Most patie nts (41.2% ) had known that the y a kidne y dise ase for 3- 6 months.

Staging of the CKD patients.

CKD Sta g e F re que nc y Pe rc e nta g e Me a n GF R 1 3 3.1 102. 2 16 16.5 73.8 3 36 37.1 44.5 4 23 23.7 25.2 5 19 19.6 10.6

T

he pr e vale nc e of late r e fe r r al/ of CKD patie nts (stage s 4 &5)=43.3%

[me an GF R=15.6(±1.6] ml/ min/ 1.73M2).

55, 56.7% 42, 43.3% E arly (S tage 1, 2 & 3) Late (S tage 4 & 5)

Pa tie nt ba se line c ha r a c te r istic s a nd the a ssoc ia tion with the la te pr e se nta ion. le ve l

Variable

L a te (n=42) E a r ly (n=55)

P value

50.70 (±15.2) 45.93 (±15.2)

0.13 Age (mean)

Frequency % Frequency %

Ge nde r

Ma le F e ma le 25 17 59.5% 40.5% 27 28 49.1% 50.9%

0.307 0.307 Ma r ita l sta tus

Sing le Ma rrie d Se pa ra te d 5 30 7 11.9% 71.4% 16.7% 15 36 4 27.3% 65.5% 7.2%

0.06 0.53 0.15

Educat cation None Primary Secon

• nda

dary Tertiar ary Lat ate (42) 42) 10 10 13 13 11 11 8 % 23. 23.8% 31. 31.0% 26. 26.2% 19. 19.0% Early y (55) 55) 15 15 14 14 16 16 10 10 % 27. 27.3% 25. 25.5% 29. 29.1% 18. 18.2% P v val alue 0. 0.70 70 0. 0.55 55 0. 0.75 75 0. 0.91 91

NO S SIGNIFICANT asso assoc b betwe ween Lat ate referral an and ag age, g gender, m mar arital st stat atus or educa cation

No sig nific a nt a sso c ia tio n b tn employment status, medical insurance and late ref

presentation.

L a te (n=42) E a rly (n=55)

c o unt % c o unt %

P- va lue

E mployme nt

E mplo ye d Un-e mplo ye d 16 26 38.1% 61.9% 21 34 38.2% 61.8%

0.993 0.993 Me dic al insur anc e No ne Ye s

27 15 64.3% 35.7% 41 14 74.5% 25.5%

0.274 0.274

Signific ant assoc iation btn patie nt’s r e side nc e and late r e fe r r al/ pr e se ntation

L a te (n=42) E a rly (n=55)

R e side nc e

c o unt % c o unt %

P- va lue Outside Na irobi Within Na irobi

36 6 85.7% 14.3% 37 18 67.3% 32.7%

0.037 0.037

Known r isk fac tor s for CKD and the assoc iation with late r e fe r r al/ pr e se ntation L

a te

(n=42)

E a r ly

( n=55) Risk fa c to r Co unt % c o unt % P-va lue Dia b e te s Me llitus 15 35.7% 22 40.0%

0.667

Hype rte nsio n 18 42.9% 19 34.5% 0.404 HIV 5 11.9% 3 5.5% 0.253 Ob struc tive uro pa thy 3 7.1% 2 3.6% 0.439 Po lyc ystic kid ne y d ise a se 6 14.3% 0% *0.004

HIV-huma n immuno de fic ie nc y virus

All the 6 patie nts with PKD pr e se nte d in CKD stage 4/ 5.

NO signific ant assoc iation btn late r e fe r r al of CKD patie nts and the r e fe r r ing he alth c ar e pr

• vide r

s.

L a te (n=42) E a r ly (n=55)

c o unt % c o unt % P-va lue

R e fe r r ing he a lth c a r e pr

• vide r

Clinic al o ffic e r (1) Me d ic al o ffic e r (66) physic ia n spe c ialist (22) Othe r spe c ia list (8) (surg e o ns & g yna e c o lo g ists) 30 8 4 .0% 71.4% 19.0% 9.5% 1 36 14 4 1.8% 65.5% 25.5% 7.3%

*0.38

0.53 0.46 0.69

NONE

• f the r

e fe r r ing he alth c ar e fac ilitie s was signific antly assoc iate d with late r e fe r r al pr e se ntation.

L a te (n=42) E a r ly (n=55)

c o unt % c o unt %

P-va lue

R e fe r r ing he a lth c a r e fa c ility

He a lth c e ntre Priva te ho spita l Distric t ho spita l Pro vinc ia l ho spita l K e nya tta N. ho spita l(K NH) 10 23 2 7 .0% 23.8% 54.8% 4.8% 16.7% 1 10 26 2 16 1.8% 18.18% 47.3% 3.6% 29.1%

*0.38 0.50 0.47 0.78 0.15

Re fe rra ls fro m KNH: Surg ic a l o ut pa tie nt c linic (SOPC) -2 Dia b e tic o ut pa tie nt c linic (DOPC)-10 Me dic a l o ut pa tie nt c linic (MOPC)-6 Gyna e c o lo g y o ut pa tie nt c linic (GOPC)-1 Ca sua lty de pa rtme nt-4

Dur ation (days) fr

• m the time patie nt was r

e fe r r e d to the time se e n by a ne phr

• logist at KNH r

e nal c linic

L ate (n=42) E ar ly (=55) Dur ation (days) me an(±SD) n=97 Me an Rank Me an Rank P- value

F r

• m r

e fe r r al to time se e n by ne phr

• logist

33.9(±1.9) 44.9 52.1 0.214 F r

• m r

e fe r r al to booking

• f appointme nt at KNH

r e nal c linic 14.8(±2.5) 48.1 49.7 0.79 F r

• m appointme nt

booking to time se e n by ne phr

• logist

15.5((±1.9) 38.4 57.1 0.001

patient Knowledge on the causes of Kidney illness

• Alcohol
• Cigarette smoking
• Diet-fats, salt
• Hypertension
• Diabetes
• Unclean water
• Weather

Pa tie nt opinion on re a sons for la te pre se nta tion

L ac k of mone y to c ate r for hospital e xpe nse s Be ing unawar e of pr e se nc e of kidne y dise ase Not knowing the tr e atme nt options for kidne y dise ase L ac k of awar e ne ss of dise ase implic ations if not tr e ate d e ar ly Poor ly e quippe d public he alth fac ilitie s Use of alte r native tr e atme nt

Conclusion

• 1. Late referral presentation of patients with CKD

to nephrologists at KNH renal clinic is highly prevalent at 43.3%.

• 2. Patient’s residence was significantly associated

with late referral presentation to the nephrologist at KNH renal clinic.

• 4. Other contributors to delayed presentation are:
• Financial difficulties
• Lack of awareness on the presence of CKD

Recommendations.

1.Need to provide affordable renal replacement services in main regional hospitals through out the country.

2.

Need to improve awareness of CKD among H/C providers and general public

3.

A study should be carried out to assess the health care provider knowledge, practices and attitude towards the care of CKD patients.

Acknowledgements

 My supervisors: Prof. Kayima

• Dr. A.J.O. Were
• Prof. Amayo

 KNH ethics committee  Patients who participated in the study  KNH Renal clinic & Renal Lab. staff

Towards a Culture of Prevention

“Today no one disputes that prevention is better and cheaper than reacting to crises after the fact. And yet our political and organizational cultures and practices remain

• riented far more towards

reaction than prevention.”

Kofi Annan, 09 / 09 /1999

Thank you.