Brendan Barrett
Professor of Medicine, Nephrology
& Clinical Epidemiology, Health Services Centre, Newfoundland, Canada
Chronic kidney disease (CKD) is becoming increasingly
recognised as a burgeoning public health problem. The extent of the problem is
not yet clear, but creatinine based assessments point to a high prevalence of
low kidney function, particularly in the elderly.1 The minority of
those affected progress to require dialysis or a transplant. Low kidney
function has been linked to cardiovascular disease and premature mortality.
Nephrologists and the health care system in general are trying to figure out
the best way to deal with the problem.
There have not been any national surveys in Canada to
establish the true prevalence of CKD. Laboratory based assessments suggest a
prevalence not dissimilar from elsewhere. Some provincial jurisdictions are
reporting creatinine based estimates of kidney function on laboratory reports.
Studies of the impact of this practice are ongoing. Some data indicate that
such reports, combined with education for GPs leads to increased recognition of
CKD. The province of British Columbia has combined lab reports of GFR with
links to guidelines for practitioners and patients on the web. Current data
suggest no resulting change in existing trends with regard to management of CKD
in general.
In Canada patients with identified low kidney function
continue to be managed at the primary and secondary care level until the GFR reaches
low levels. In the ongoing Can-Care cohort study of the impact of elements of
care on outcomes, the average GFR of a cohort seen by a nephrologist for the
first time was 28 mls/min.* This study along with many others also documents
the under investigation and underuse of efficacious therapies among those at
risk.
In an effort to better determine how to manage those
with CKD, a multicentre clinical trial comparing usual care to a nurse-based,
protocol guided approach involving a nephrologist (Can-Prevent) is enrolling to
a pilot phase currently.* The hope is to examine the effect of a new way of
delivering care to those with CKD on cardiovascular and kidney outcomes.
There also remains uncertainty in who should care for
those with non-progressive CKD, and what should be done for them. Existing
Canadian guidelines published in 1999 are now outdated and are being revised.
Primary health care is currently a focus of attention in Canada, with many
jurisdictions experimenting with renewal and reform of the system.
Incorporation of principles of chronic disease management may enhance the care
of conditions like CKD in the future. However, the fact that the Canadian
health care system is provincially based and thus varied means that no one
solution is likely to fit all jurisdictions.
References
1. Duncan et al. Nephrol Dial Transplant 2001; 16:
1042–1046. 2001
* Please note that the Can-Care and Can-Prevent
studies are ongoing, and data has not yet been published from them.