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 ESRD 1 .  Timing & quality of care before dialysis affects morbidity and mortality in CKD patients 2 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 services 3 •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 obviates the opportunity for significant delay of 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 15 12 Frequency 9 6 3 Mean = 48.01 Std Dev. =15.34 0 20 40 60 80 Age Me an age = 48.01(±15.34) ye ar s Range :18- 88 yr s Pe ak = 50- 55 ye ar s. = 1.2:1. Male s=52 F e male s=45; M: F

So c io - de mo g r a phic c ha r a c te r istic s F a c to r n=97 F r e q ue nc y Pe r c e nta g e Ma r ita l Sta tus • Sing le 20 20.6 • Ma r r ie d 66 68.0 • Se p a r a te d 11 11.3 E duc a tio n • No ne 25 25.8 • Pr ima r y 27 27.8 • Se c o nd a r y 27 27.8 • T e rtia ry 18 18.6 37 38.1 E mplo ye d Me dic a l insur a nc e 29 29.9

Re side nc e 40 35.6 35 30 26 25 Per cent 20 16.3 15 10.6 10 6.7 2.9 5 1 1 0 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 38.1 40 38.1 35 30 25 Pe r c e nt 20 15 8.2 6.3 10 5.2 2.1 5 0 PKD N DM HIV Obstruc tive He pa titis B HT Uropa thy Known risk for CKD 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

Dur ation that patie nts had known of the diagnosis of kidne y dise ase [fr om the ir pr i. he alth c ar e pr ovide 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 . 3- 6 months. Most patie nts (41.2% ) had known that the y a kidne y dise ase for

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 al/ of CKD patie nts (stage s 4 &5)=43.3% T he pr e vale nc e of late r e fe r r [me an GF R=15.6(±1.6] ml/ min/ 1.73M 2) . 42, 43.3% E arly (S tage 1, 2 & 3) 55, 56.7% 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. P value le ve l L a te (n=42) E a r ly (n=55) Variable 0.13 50.70 (±15.2) 45.93 (±15.2) Age (mean) % % Frequency Frequency Ge nde r Ma le 25 59.5% 27 49.1% 0.307 F e ma le 17 40.5% 28 50.9% 0.307 Ma r ita l sta tus Sing le 5 11.9% 15 27.3% 0.06 Ma rrie d 30 71.4% 36 65.5% 0.53 Se pa ra te d 7 16.7% 4 7.2% 0.15

Educat cation Lat ate (42) 42) % Early y % P v val alue (55) 55) 10 10 None 23.8% 23. 15 15 27.3% 27. 0. 0.70 70 13 13 Primary 31. 31.0% 14 14 25.5% 25. 0. 0.55 55 11 11 Secon onda dary 26. 26.2% 16 16 29. 29.1% 0.75 0. 75 8 Tertiar ary 19. 19.0% 10 10 18.2% 18. 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 16 38.1% 21 38.2% 0.993 E mplo ye d 26 61.9% 34 61.8% 0.993 Un-e mplo ye d Me dic al insur anc e No ne 27 64.3% 41 74.5% 0.274 Ye s 15 35.7% 14 25.5% 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) P- va lue c o unt % c o unt % R e side nc e Outside Na irobi 36 85.7% 37 67.3% 0.037 Within Na irobi 6 14.3% 18 32.7% 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 Risk fa c to r L a te E a r ly (n=42) ( n=55) P-va lue Co unt % c o unt % 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% *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 ovide r s. L a te (n=42) E a r ly (n=55) P-va lue c o unt % c o unt % R e fe r r ing he a lth c a r e pr ovide r * 0.38 Clinic al o ffic e r (1) 0 .0% 1 1.8% 0.53 Me d ic al o ffic e r (66) 30 71.4% 36 65.5% 0.46 physic ia n spe c ialist (22) 8 19.0% 14 25.5% 0.69 Othe r spe c ia list (8) 4 9.5% 4 7.3% ( surg e o ns & g yna e c o lo g ists )

NONE of 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) P-va lue c o unt % c o unt % R e fe r r ing he a lth c a r e fa c ility *0.38 He a lth c e ntre 0 .0% 1 1.8% 0.50 Priva te ho spita l 10 23.8% 10 18.18% 0.47 Distric t ho spita l 23 54.8% 26 47.3% 0.78 Pro vinc ia l ho spita l 2 4.8% 2 3.6% 0.15 K e nya tta N. ho spita l(K NH) 7 16.7% 16 29.1% 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 om the time patie nt was r e fe r r e d to the time se e n by a ne phr ologist at KNH r e nal c linic Dur ation (days) me an(±SD) L ate (n=42) E ar ly (=55) n=97 P- value Me an Rank Me an Rank 0.214 F r om r e fe r r al to time se e n 33.9(±1.9) 44.9 52.1 by ne phr ologist 0.79 F r om r e fe r r al to booking 14.8(±2.5) 48.1 49.7 of appointme nt at KNH r e nal c linic F r om appointme nt 15.5((±1.9) 38.4 57.1 0.001 booking to time se e n by ne phr ologist

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