Effectiveness of adherence to a renal health program in a health network in Peru / Efectividad de la adherencia a un programa de salud renal en una red sanitaria de Perú

ABSTRACT OBJECTIVE To evaluate the effectiveness of adherence to a multidisciplinary renal health program in reducing mortality and progression to hemodialysis. METHODS We used a database that included patient monitoring (2013-2017), dialysis admissions and all cause of mortality in Peru. Adherence to the program was established by meeting minimum visits during the first year of monitoring. The outcome of interest was hemodialysis admissions or all cause-mortality. Kaplan-Meier curves, Log-Rank test and competing survival analysis methods were used to estimate the differential risk between adherent and non-adherent patients. RESULTS A total of 20,354 participants was evaluated; 54.1% were male, 72.1 years old in average, 2.2 years average follow-up, and 15,279 (75.1%) belonged to the early stages (1 to 3a) of Chronic Kidney Disease. Adherence decreased the risk of renal replacement therapy in 41.0% (HR = 0.59, 95%CI 0.41-0.85) in the low-risk group and mortality in the high-risk group was 31.0% (HR = 0.69, 95%CI 0.57-0.83). CONCLUSIONS The multidisciplinary care strategy with standardized assessments by stage is effective in reducing admission to .0when the patient is identified in early stages and in reducing mortality in advanced stages.

RESUMEN OBJETIVO Evaluar la efectividad de la adherencia a un programa de salud renal en la reducción de mortalidad y progresión a hemodiálisis. MÉTODOS Utilizamos una base de datos que condensaba el seguimiento de los pacientes (2013-2017), los ingresos a diálisis de los mismos y la mortalidad por todas las causas en Perú. La adherencia al programa se estableció con el cumplimiento de visitas mínimas durante su primer año de seguimiento. La efectividad de la adherencia al programa se midió en términos de debut a hemodiálisis o muerte por todas las causas. Se utilizaron curvas de Kaplan-Meier, test de diferencias en la distribución (Log-Rank test) y métodos de análisis de supervivencia. Los análisis se realizaron utilizando R estudio 3.5.0 RESULTADOS Fueron evaluados 20.354 participantes, 54,1% varones, edad media de 72,1 años, con un seguimiento medio de 2,2 años; 15.279 (75.1%) tuvieron ERC en estadios tempranos (estadio 1 al 3a). La adherencia disminuyó en un 41,0% el riesgo de terapia de reemplazo renal (HR = 0,59; IC95% 0,41-0,85) en el grupo de bajo riesgo y en un 31,0% (HR = 0,69; IC95% 0,57-0,83) la mortalidad en el grupo de alto riesgo. CONCLUSIONES La estrategia de cuidado multidisciplinario con evaluaciones estandarizadas según estadio es efectiva en reducir el ingreso a terapia de reemplazo renal cuando se identifica al paciente en estadios tempranos y en reducir la mortalidad en estadios avanzados.

Early detection of chronic renal disease: coordinated work between primary and specialized care in an ambulatory renal network of Peru / Detecção precoce de doença renal crônica: trabalho coordenado entre atenção primária e especializada em uma rede peruana de atenção renal ambulatorial

Abstract Introduction: The aim of the study was to report the implementation of a functional network for the early diagnosis of chronic kidney disease (CKD) in patients with risk factors and the coordinated work between primary and specialized care in social security in Perú. Material and methods: A cross-sectional analysis of the data of patients evaluated in a health network in the city of Lima (2013 to 2016), older than 18 years, with risk factors for CKD, evaluated with serum creatinine and creatine albumin ratio in random urine (ACR). A multivariate logistic regression analysis was performed to evaluate the factors associated with the finding of CKD. Results: The implementation included training in renal health, installation of a digital database, organization of laboratories, and empowerment of primary care. We evaluated 42,746 patients of which 41.8% were men, with median age 69.2 years. The most frequent cause of detection was hypertension (HBP): 23,921 (55.9%). The prevalence of CKD was 12,132 (28.4%), the most frequent stage of CKD was 3a: 4735 (39.0%). Of the total, 6214 (14.5%) patients had microalbuminuria and 1335 (3.1%), macroalbuminuria. The risk of CKD increased 2.5 times (95% CI: 2.3-2.7) in patients with diabetes (DM) and HBP, in men (OR 1.2, 95% CI: 1.2-1.3) and as age increased (> 77 years: OR 2.7, 95% CI: 2.5-2.8). The identification of the disease in the primary care setting is 60% less likely than in specialized care. Conclusions: One of every four patients are diagnosed with CKD, and the simultaneous diagnosis of DM and HBP and old age are the most important factors.

Resumo Introdução: O objetivo do presente estudo foi descrever a implementação de uma rede funcional para o diagnóstico precoce de doença renal crônica (DRC) em pacientes com fatores de risco e o coordenar os trabalhos entre atenção primária e especializada no sistema de seguridade social peruano. Material e métodos: Análise transversal dos dados de pacientes maiores de 18 anos com fatores de risco para DRC avaliados em uma rede de saúde na cidade de Lima (2013 a 2016) por meio de creatinina sérica e relação albumina/creatinina (RAC) em amostra aleatória de urina. Análise de regressão logística multivariada foi executada para avaliar os fatores associados à presença de DRC. Resultados: A implementação incluiu treinamento em saúde renal, instalação de um banco de dados digital, organização de laboratórios e empoderamento da atenção primária. Foram avaliados 42.746 pacientes, dos quais 41,8% eram homens, com idade mediana de 69,2 anos. A causa mais comum de detecção foi hipertensão, observada em 23.921 indivíduos (55,9%). A prevalência de DRC foi de 12.132 (28,4%), com estágio 3A sendo o mais frequente com 4735 casos (39,0%). Do total, 6214 (14,5%) pacientes apresentavam microalbuminúria e 1335 (3,1%) macroalbuminúria. O risco de DRC foi 2,5 vezes maior (IC 95%: 2,3-2,7) nos pacientes com diabetes e hipertensão, em homens (OR 1,2, IC 95%: 1,2-1,3) e idosos (> 77 anos: OR 2,7, IC 95%: 2,5-2,8). A identificação da doença no cenário da atenção primária é 60% menos provável do que na atenção especializada. Conclusões: Um em cada quatro pacientes é diagnosticado com DRC. Idade avançada e diagnóstico simultâneo de DM e hipertensão são os fatores mais relevantes.

Progresión de enfermedad renal crónica en un hospital de referencia de la seguridad social de Perú 2012-2015 / Progression of chronic renal disease in a reference hospital of social security of Peru 2012-2015

RESUMEN Objetivos. Describir las características de la población con enfermedad renal crónica (ERC) estadio 3 y 4, determinar los factores asociados a progresión de ERC y a ingreso a terapia de reemplazo renal (TRR), así como la sobrevida renal. Materiales y métodos. Estudio retrospectivo longitudinal de pacientes remitidos entre enero de 2012 y diciembre de 2015 a la Unidad de Salud Renal del Hospital Nacional de Edgardo Rebagliati Martins (HNERM), quienes fueron evaluados y seguidos por un equipo multidisciplinario. Los datos clínicos y de laboratorio de cada consulta se registraron en un software creado específicamente para el programa. Se realizó un análisis de regresión logística multivariado para evaluar los factores asociados con la progresión de la ERC, un modelo de regresión de Cox para predecir el riesgo de ingresar al TRR y el método de Kaplan-Meier para el análisis de supervivencia renal. Resultados. Se evaluó a 1248 pacientes en estadio 3A: 248 (20%), estadio 3b: 548 (44%) y estadio 4: 452 (36%). 352 (28%) progresaron, siendo la proteinuria el factor de progresión más importante (OR: 3,2; IC95%: 2,2-4,6). La proteinuria incrementa el riesgo de ingreso a la TRR en cuatro veces y el tener una tasa de filtración glomerular <30% en 3,6 veces. La mediana de seguimiento fue de 12 meses (RIC 5-27 meses). 92 pacientes (7%) requirieron iniciar TRR. La supervivencia renal a los 12 meses de seguimiento fue del 96% y a los 24 meses de 90%. Conclusiones. Nuestro estudio muestra que en un centro especializado una proporción significativa de pacientes con ERC no progresa en su enfermedad y que el factor que más se asocia a progresión de enfermedad y a inicio de TRR es la proteinuria.

ABSTRACT Objectives. To describe the characteristics of the population with chronic kidney disease (CKD) stage 3 and 4, to determine the factors associated with CKD progression and admission to renal replacement therapy (RRT), as well as renal survival. Materials and methods. Longitudinal retrospective study of patients referred between January 2012 and December 2015 to the Renal Health Unit of the Hospital Nacional Edgardo Rebagliati Martins (HNERM), who were evaluated and followed by a multidisciplinary team. The clinical and laboratory data for each query were recorded in a software created specifically for the program. A multivariate logistic regression analysis was performed to assess the factors associated with the progression of CKD, a Cox regression model to predict the risk of entering RRT and the Kaplan-Meier method for renal survival analysis. Results. We assessed 1248 patients in stage 3A: 248 (20%), stage 3B: 548 (44%) and stage 4: 452 (36%). 352 (28%) progressed, being proteinuria the most important progression factor (OR: 3.2; CI 95%: 2,2-4.6). Proteinuria increases the risk of admission to RRT in four times and having a glomerular filtration rate < 30% in 3.6 times. Median follow-up was 12 months (RIC 5-27 months). 92 patients (7%) required to initiate RRT. Renal survival at 12 months of follow-up was 96% and at 24 months was 90%. Conclusions. Our study shows that in a specialized center a significant proportion of patients with CKD does not progress in their disease and that the factor that is most associated with progression of disease and at the onset of RRT is proteinuria.