Timeliness in chronic kidney disease and albuminuria identification: a retrospective cohort study

Simon DS Fraser, Julie Parkes, David Culliford, Miriam Santer, Paul J Roderick

Chronic kidney disease (CKD) is predominantly managed in primary care in the UK, but there is evidence of under-identification leading to lack of inclusion on practice chronic disease registers, which are necessary to ensure disease monitoring. Guidelines for CKD patients recommend urinary albumin to creatinine ratio (uACR) testing to identify albuminuria to stratify risk and guide management. This study aimed to describe the pattern and associations of timely CKD registration and uACR testing. A retrospective cohort of individuals with incident CKD 3-5 (two estimated glomerular filtration rates (eGFR) <60 ml/min/1.73 m(2) ≥ three months apart) between 2007 and 2013 was identified from a linked database containing primary and secondary care data. Descriptive statistics and Cox proportional hazards models were used to identify associations with patient characteristics of timely CKD registration and uACR testing (within a year of first low eGFR). 12,988 people with CKD 3-5 were identified from 88 practices and followed for median 3.3 years. During this time period, 3235 (24.9%) were CKD-registered and 4638/12,988 (35.7%) had uACR testing (median time to CKD registration 307 days and to uACR test 379 days). 1829 (14.1%) were CKD-registered and 2229 (17.2%) had uACR testing within one year. Amongst people whose CKD was registered within a year, 676/1829 (37.0%) had uACR testing within a year (vs. 1553/11,159 (13.9%) of those not registered (p < 0.001)). Timely uACR testing varied by year, with a sharp rise in proportion in 2009 (when uACR policy changed). Timely CKD registration was independently associated with lower eGFR, being female, earlier year of joining the cohort, having diabetes, hypertension, or cardiovascular disease but not with age. Timely uACR testing was associated with timely CKD registration, younger age, having diabetes, higher baseline eGFR and later year of joining the cohort. Better systems are needed to support timely CKD identification, registration and uACR testing in primary care in order to facilitate risk stratification and appropriate clinical management.