Patient Management and Clinical Outcomes Associated with a Recorded Diagnosis of Stage 3 Chronic Kidney Disease: The REVEAL-CKD Study

Abstract

Guidelines for the treatment of chronic kidney disease (CKD) recommend early intervention and management to slow disease progression. However, associations between diagnosis and CKD progression are not fully understood. REVEAL-CKD (NCT04847531) is a retrospective observational study of patients with stage 3 CKD. Data were extracted from the US TriNetX database. Eligible patients had two consecutive estimated glomerular filtration rate (eGFR) measurements indicative of stage 3 CKD (≥ 30 and < 60 ml/min/1.73 m2) recorded 91–730 days apart from 2015 to 2020. Diagnosed patients were included if their first CKD diagnosis code was recorded at least 6 months after their second qualifying eGFR measurement. We assessed CKD management and monitoring practices for the 180 days before and after CKD diagnosis, annual eGFR decline in the 2 years before and after CKD diagnosis, and associations between diagnostic delay and post-diagnosis event rates. The study included 26,851 patients. After diagnosis, we observed significant increases in the prescribing rate of guideline-recommended medications such as angiotensin-converting enzyme inhibitors (rate ratio [95% confidence interval]: 1.87 [1.82, 1.93]), angiotensin receptor blockers (1.91 [1.85, 1.97]) and mineralocorticoid receptor antagonists (2.23 [2.13, 2.34]). Annual eGFR decline was significantly reduced following a CKD diagnosis, from 3.20 ml/min/1.73 m2 before diagnosis to 0.74 ml/min/1.73 m2 after diagnosis. Delayed diagnosis (by 1-year increments) was associated with elevated risk of CKD progression to stage 4/5 (1.40 [1.31–1.49]), kidney failure (hazard ratio [95% confidence interval]: 1.63 [1.23–2.18]) and the composite of myocardial infarction, stroke and hospitalization for heart failure (1.08 [1.04–1.13]). A recorded CKD diagnosis was associated with significant improvements in CKD management and monitoring practices and attenuated eGFR decline. Recorded diagnosis of stage 3 CKD is an important first step to reduce the risk of disease progression and minimize adverse clinical outcomes. ClinicalTrials.gov identifier, NCT04847531. Chronic kidney disease (CKD) is a long-term condition in which the function of the kidneys is reduced. Kidney function is monitored using a measurement called the estimated glomerular filtration rate. CKD can be separated into stages of severity, ranging from 1 (mild) to 5 (severe), using estimated glomerular filtration rate. Mild to moderate CKD (stages 1–3) is difficult to diagnose because there are usually no symptoms. In this study from the REVEAL-CKD programme, we looked at the effects of having undiagnosed stage 3 (moderate) CKD and examined how a CKD diagnosis affects disease management and worsening of the condition. Using a database of medical records for patients in the USA called TriNetX, we looked at data from over 26,000 patients with stage 3 CKD who were identified using estimated glomerular filtration rate measurements. We found that healthcare teams prescribed significantly more guideline-recommended medications and did more clinical monitoring in the 180 days after a CKD diagnosis than they did before the diagnosis. Additionally, the rate of decline in kidney function slowed after a CKD diagnosis. Delaying diagnosis by 1 year increased the risk of deterioration of the condition by 40%, the risk of needing a kidney transplant or long-term dialysis treatment by 63% and the risk of major heart and blood vessel diseases (known as cardiovascular events) by 8%. Our findings suggest that diagnosis of stage 3 CKD is an important first step to reduce the risk of the disease worsening and other complications.

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