Early detection and prevention of chronic kidney disease

The global burden of chronic kidney disease (CKD) is significant, and largely fuelled by the epidemics of diabetes and hypertension. CKD is a major risk factor for end-stage kidney disease (ESKD), cardiovascular disease (CVD) and premature death. In Australia, data on the prevalence of CKD are limited, and the best available evidence to estimate the CKD burden is drawn from renal replacement therapy (RRT) data. At the end of 2015, the number of patients receiving RRT was 968 per million population and continuing to rise. Evidence suggests that progression and adverse outcomes of CKD can be prevented or delayed by detecting and treating the disease in its initial stages. Unfortunately, CKD is asymptomatic until the kidney function declines by up to 90%; this makes it essential to detect the disease early. Hence, many clinical practice guidelines recommend that individuals with risk factors should be screened for CKD. In light of this evidence, globally, several targeted screening programs have been implemented in various community settings. However, the overall success of these programs is uncertain. Therefore, the aim of Project I was to conduct a systematic review of the literature to determine whether targeted screening programs are effective in identification of early stages of CKD. Despite advancements in the early detection and prevention of CKD, availability of clinical practice guidelines, and development of risk stratification tools, 17% of new patients were referred late to nephrologists for the management of ESKD in Australia. Pharmacists are highly accessible and in a good position to engage people within the community who are not aware of their risks and less likely to access general practice care. Thus, a pharmacist-initiated CKD risk assessment service could help to identify at-risk patients and refer them to general practitioners (GP) for further evaluation and management. Therefore, the aim of Project II was to implement and evaluate a CKD risk assessment service in community pharmacies. Public awareness of CKD is an important determinant of the uptake of screening programs, which may help to address the CKD burden. However, there is a lack of understanding amongst the Australian community about the preventability of major health conditions. Additionally, even amongst sub-group of Australian cohorts with the greatest risk of CKD, the knowledge of CKD risk factors and the recall of kidney function testing were found to be limited. Hence, a final Project III to determine the Australian public knowledge about CKD was conducted. Aim of the thesis The overall aim of this thesis was to identify and implement strategies that could help to improve the early detection and management of CKD in Australia. Methods Project I All observational studies of targeted screening programs implemented in any community-based setting were systematically identified and analysed. The main outcome measures were the percentage of participants with positive screening results and diagnosed with CKD at follow-up, and screening tests used to detect evidence of CKD. Project II A prospective cohort study in 24 Tasmanian community pharmacies was conducted. Prior to implementation, community pharmacists were trained to perform the CKD risk assessment service. Pharmacists were required to identify people with CKD risk factors and recruit them for risk assessment. The QKidney® risk calculator was used to estimates the eligible participants’ five-year percentage risk of developing moderate-severe CKD. Participants identified with ≥ 3% risk were referred to their GP and followed-up after nine months. Next, laboratory data were collected from the pathology provider. The main outcome measures were rates of GP referral uptake and of participants who underwent estimated glomerular filtration rate (eGFR) and urine albumin creatinine ratio (ACR) measurement. Community pharmacists’ qualitative interviews were conducted, post-intervention, to explore the challenges faced by them during the implementation of the CKD service. Lastly, patient satisfaction with the CKD service was evaluated using a nine-item satisfaction survey which also included an additional question on willingness to pay. Project III A 24-item CKD knowledge questionnaire was developed, validated and used to conduct an online cross-sectional survey of the Australian public. Participants could achieve a maximum score of 24 on the questionnaire. Next, a standard multiple regression analysis was performed to identify predictors of the public knowledge of CKD. Results and discussion Project I Out of nine studies included in the systematic review analysis, eight reported the percentage of participants with positive screening test results, which ranged from 7% to 60.3%. The percentage of participants diagnosed with CKD at follow-up was reported by only two studies, which was 17.1% and 20.5%. The most commonly used screening tests were ACR (≥ 3.4 mg/mmol) and eGFR (< 60 mL/min/1.73m\(^2\)). Our analysis showed that although a considerable percentage of participants are being identified with positive screening test results, follow-up diagnostic tests for these participants was either not reported or performed by many studies. In general, this review indicated that screening programs should appropriately use the clinical guidelines in order to detect CKD. These steps are vital to determine the actual effectiveness of targeted screening and prevent over-diagnosis. Project II A total of 389 participants were recruited by the pharmacies, 203 (52.1%) of whom had ≥ 3% five-year risk of developing moderate-severe CKD and were referred to their GP. Follow-up was successful for 126 participants and showed low (27%) GP referral uptake. Analysis of the pathology data revealed suboptimal kidney testing in participants with ≥ 3% risk, with eGFR and ACR tests performed for only 52.7% and 25.1% of these participants, respectively. Thus, although the in-pharmacy CKD risk assessment service, with its targeting, identified a high proportion of people at ≥ 3% risk of developing moderate-severe CKD within five years, the low GP referral uptake was a major hindrance to the efficacy of the service. The qualitative analysis showed that pharmacists found the CKD service to be efficient, user-friendly and of significant benefit to their customers. However, several pharmacists observed that customers lacked interest in disease prevention, and had limited understanding of CKD. More importantly, pharmacists perceived the scope of pharmacy practice to be significantly dependent on the inter-professional collaboration between pharmacists and general practitioners (GPs), and customers’ acknowledgement of the role of pharmacists in disease prevention. Responses to the satisfaction survey (n = 143) revealed that the majority of the participants agreed that the time required to undergo the risk assessment process was justified (90.2%), overall they were satisfied with the CKD risk assessment service (90.0%), and they felt comfortable with the pharmacist referring their results to their doctor (88.9%). Of 136 participants who answered the question on willingness to pay, 62.9% indicated that they would pay for the CKD service. Project III A total of 934 participants (Australian public ≥ 18 years) provided complete responses to the CKD knowledge questionnaire. The mean (SD) knowledge score of the Australian public was 10.3 (± 5.0) out of 24. In the multivariate analysis, the statistically significant predictors of the knowledge score were level of education, marital status (lower scores in those who were single/never married), a family history of kidney failure and a personal history of diabetes. The results of this survey showed that the Australian public knowledge of CKD was relatively poor. Conclusion Overall, the projects described in this thesis identified some effective strategies which could help to improve the early detection and management of CKD, and consequently, reduce its burden in Australia. Primarily, it was established that any targeted CKD screening program must adhere to the clinical practice guidelines on early CKD detection, prevention and management. Next, it was determined there is a significant scope for improving the public awareness of CKD and its early detection via implementation of a community pharmacy-based CKD risk assessment service. However, there is a need to explore effective strategies which would help to improve the inter-professional collaboration between community pharmacists and GPs. Additionally, integrating the CKD service with other pharmacy services, such as medication review, and providing verbal education to participants during risk assessment may help to improve its feasibility. Lastly, it was ascertained that there is a need to improve the public understanding of kidneys and knowledge on CKD through nationwide awareness programs