CKD Management in the Age of Telenephrology: An Observational Analysis of a Hybrid Telenephrology System within a Veteran's Affairs Medical Center.

Background: Nephrology has seen an uptake in transition to remote care delivery. The impact of telenephrology care on chronic kidney disease (CKD) progression is not well defined.

Methods: We analyzed data from patients naturally selected for telenephrology versus standard, in-person visits. Patients were seen across 4,230 visits over a 2-year period at a nephrology clinic within the Veterans Affairs health system. Baseline characteristics and health profile data were assessed based on grouping of individuals to the telenephrology group (>50% virtual visits) or in-person group (≤50% virtual visits). The slope of eGFR change over time was estimated for each patient using a random effects regression model and compared across groups using weighted linear regression models.

Results: A total of 1,098 patients comprised the final analysis. The groups were similar across baseline demographics and health profiles, although more cardiovascular disease, congestive heart failure, and diabetes mellitus were present in the in-person group. There was no significant difference in eGFR decline between groups, though those in telenephrology group trended toward less steep decline compared to those seen predominately in-person (telenephrology slope versus in-person slope; difference = 0.81mL/min/1.73 m2; 95% CI: -0.447, 2.08; p=0.21). Those seen primarily in-person had a similar degree of proteinuria compared to those in telenephrology (p=0.12). All-cause mortality and incidence of outpatient renal replacement therapy initiation was similar. Telenephrology patients had an average of 1.3 fewer emergency department visits per individual compared to their in-person counterpart (2.17 versus 3.44, p<0.001), as well as fewer hospital admissions (1.59 versus 2.08, p=0.02). Those in the in-person group were more often prescribed SGLT-2 inhibitors, statins, NSAIDs, and potassium supplements.

Conclusions: Data from this observational study within a VA healthcare system suggests that medically complex, multi-morbid CKD patients can expect a similar rate of eGFR decline when care is delivered via a hybrid system that includes a majority of telenephrology when compared to those managed in face-to-face visits. Further studies are needed to corroborate findings and ensure generalizability outside of this VA system.