Optimising care: Impact of regular nephrologist appointments on clinical outcome for chronic kidney disease patients in primary care.

Introduction: The rise in the cases of chronic kidney disease (CKD) with the increasing prevalence of non-communicable diseases such as type 2 diabetes mellitus and hypertension is a major public health concern in Malaysia. This results in the many cases of chronic kidney disease being managed in primary healthcare clinics. This study examines the pre- and post-clinical outcomes of scheduled nephrologist visits on CKD patients in a primary health care clinic in Ipoh, Perak.

Materials and methods: This is a retrospective crosssectional study reviewing the medical records of patients seen by visiting nephrologists from January 2019 to December 2021 in Greentown Health Clinic. The study population are patients with CKD stage 3b, 4 and 5 who are followed up in Greentown Health Clinic. Universal sampling was done, a total of 87 patients reviewed at least once by the visiting nephrologist and with retrievable medical records were included in the study. Those whose medical records were irretrievable were excluded. Blood pressure, urine protein, fasting blood sugar (FBS), glycated haemoglobin (HbA1c), serum creatinine, eGFR and fasting lipid profile (FLP) pre- and post-visits were collected by reviewing patient medical records and laboratory results. The results were then analysed and compared using SPSS version 26.

Results: The median age of patients in this study was 66 years of age, the majority were male patients (54%) and Malay ethnicity (62.1%). Absence of urine microalbuminuria pre and post referral remain the same (n = 11). During prenephrologist visits, a higher percentage of patients exhibited moderate (30-300 mg/g) and severe (>300 mg/g) increase in urine albuminuria (15.7% and 7.2%, respectively) compared to the post-referral period. In patients with significant urine protein pre-referral, patient group with urine protein 3+ showed the highest increment of 30.1% (n = 22), in comparison to 19.3% (n = 16) observed during prereferral. Statistically significant clinical outcomes between pre- and post-referral to the nephrologist include reduction of systolic blood pressure [141±15 mmHg versus 135 ±12 mmHg, p = 0.001] and diastolic blood pressure [median = 80 mmHg (IQR: 10) versus median=71 mmHg (IQR: 17), p < 0.001]. Similarly, total cholesterol [median = 4.4 mmol/L (IQR: 1.4) versus median = 4.0 mmol/L (IQR: 1.5, p = 0.001] and LDL [median = 2.5 mmol/L (IQR: 1.2) versus median = 2.2 mmol/L (IQR: 1.2), p < 0.001)] exhibited statistically significant differences between pre- and post-referral. However, HDL remained unchanged and other outcome variables showed no significant differences.

Conclusion: Incorporating nephrologist visits in primary care seems to have positive impact towards patient clinical outcomes. Results shown in this study can aid other primary care clinics in the decision to initiate nephrologist services in the primary care setting as a multidisciplinary approach to managing CKD patients.