1. UNDERDIAGNOSIS OF CHRONIC KIDNEY DIESEASE IN THE NURSING HOME
Jeffrey Cohen, MD1, Sheikh Jasimuddin, MD2, Barbara C. Tommasulo, MD, CMD, LNHA2, Yosef D. Dlugacz, PhD3, Charles Cal, RN, MS, MBA2,
Roshan Hussain, MPH, MBA3, Edan Shapiro4, Avi Singavaparu4, Joshua Vernatter4, and Gisele Wolf-Klein, MD1
1Long Island Jewish Medical Center, 2Cold Spring Hills Center for Nursing & Rehabilitation, 3Krasnoff Quality Management Institute, 4Albert Einstein College of Medicine of Yeshiva University
ABSTRACT
Background: Early diagnosis of chronic kidney disease (CKD) in the elderly allows for the implementation of measures proven to delay progression to dependence on dialysis, reduce risk for cardiac complications, and improve medication management. Given that the National Kidney Foundation (NKF) published stage-based protocols (2002) to delay/prevent outcomes associated with CKD, it is incumbent upon physicians to recognize CKD. The purpose of this study is to explore how frequently elderly nursing home residents who qualify for the diagnosis of CKD using NKF criteria are actually recognized by their physicians as having CKD.
Methods: A retrospective chart review was performed on all long-term elderly residents within a 672-bed facility who had resided there for at least 6 months and whose records included at least two serum creatinine levels drawn at least 90 days apart from each other. Each subject's monthly internist progress notes were reviewed to determine if the subject had received a clinical diagnosis of CKD. Glomerular filtration rates (GFRs) were calculated via the Modified Diet in Renal Disease (MDRD) and Cockcroft-Gault formulas.
Results: 280 subjects cared for by 30 internists were studied. The majority (70%) were women; average patient age was 83.1 years. Of the 71 subjects who had CKD by MDRD criteria, 62.0% had not been diagnosed by their physicians. Of subjects with CKD by Cockcroft-Gault criteria, 82.0% had not been formally diagnosed.
Conclusion: Despite well-established criteria for the diagnosis, CKD remains exceedingly underdetected within the nursing home, placing this community at increased risk for costly, avoidable outcomes.
METHODS
A retrospective chart review was performed on all long-term residents within a 672-bed nursing home who had resided there for at least 6 months and whose records included at least two serum creatinine levels drawn at least 90 days apart from each other. Each subject’s monthly internist progress notes over the past 6 months were reviewed to determine if the subject had received a clinical diagnosis of CKD. The two most recent serum creatinine levels 90 days apart from each other were recorded. Data was incorporated into Modified Diet in Renal Disease (MDRD) and Cockcroft-Gault formulas to determine subjects’ glomerular filtration rates (GFRs). GFRs consistently below 60 milliliters per minute per 1.73 square meters of body-surface area were categorized as positive screening tests for CKD.
DISCUSSION
We recognize that the Cockcroft-Gault equation is overly sensitive for CKD in the elderly, likely at the expense of specificity for the disease. This may account for the notable discrepancy in subjects with CKD by Cockcroft-Gault criteria versus MDRD criteria. While we place significantly more value on GFRs calculated from the MDRD equation, we decided to include data from the Cockcroft-Gault equation primarily due to our appreciation of the continued widespread use and acceptance of the Cockcroft-Gault equation by physicians throughout the United States.
CONCLUSION
Despite well-established criteria for the diagnosis, CKD remains exceedingly underdetected within the nursing home, placing this community at increased risk for costly, avoidable outcomes, including therapeutic polypharmacy. Greater awareness of clinical guidelines for detection of CKD is needed for prudent geriatric practice.
RESULTS
Two hundred eighty subjects cared for by 30 internists were studied. The majority (70%) were women; average patient age was 83.1 years. Seventy one subjects qualified as having CKD by MDRD criteria; 44 of these subjects (62.0%) had yet to be diagnosed with CKD (Fig. 1). 167 subjects qualified into the diagnosis based on Cockcroft-Gault criteria; 137 (82.0%) had not been formally diagnosed (Fig. 2).
REFERENCES
Coresh J, Astor BC, Green T, et al. Prevalence of Chronic Kidney Disease and Decreased Kidney Function in the Adult US Population: Third National Health and Nutrition Examination Survey. Amer J Kidney Dis 2003;41:1-12.
Go AS, Glenn MC, Fan D et al. Chronic Kidney Disease and the Risks of Death, Cardiovascular Events, and Hospitalization. N Engl J Med 2004;351:
Fried LP, Kronmal RA, Newman AB, et al. Risk Factors for 5-Year Mortality in Older Adults – The Cardiovascular Health Study. JAMA 1998;279:585-92
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39: S1-266.
Chronic Kidney Disease (CKD) is both prevalent in the American geriatric community and rapidly increasing in prevalence within this population. While 12% of Americans over 64 years old currently have CKD, it is estimated that this number will have increased to 16.5% by CKD can be a devastating disease, leading not only to the need for dialysis, but inducing complications in virtually any organ system. It has been shown to be an independent predictor of adverse outcomes including cardiovascular disease and mortality itself2-3. Given that in 2002 the National Kidney Foundation (NKF) KDOQI published stage-based protocols to delay/prevent outcomes associated with CKD, it is now incumbent upon physicians to recognize CKD in a timely manner. It has been suggested that CKD is underdiagnosed, and hence, undertreated, in the general population1,4. Nonetheless, a dearth of studies have been performed to assess whether an appropriate percentage of American geriatric patients are being diagnosed with CKD. The purpose of this study is to explore how frequently elderly nursing home residents who qualify for the diagnosis of CKD using NKF criteria are actually recognized by their physicians as having CKD.
Cockcroft-Gault Equation:
(140-age) x weight [kg]
serum creatinine [mg/dL] X 72 
MDRD Equation:
186 x (serum creatinine) x (age) –0.203
x (0.742 if female) x (1.210 if African American)