Navigating the Challenges of Evidence-based Chronic Kidney Disease Care

Joseph A Vassalotti
US Nephrology, 2011;6(2):74-79
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Abstract

Informing chronic kidney disease (CKD) care is limited because of the paucity of evidence from randomized controlled trials (RCTs). Available RCTs typically compare one intervention to placebo for a single condition, whereas CKD patients show high comorbidity and require multiple interventions. Fortunately, CKD clinical practice guidelines from the Kidney Disease Outcomes Quality Initiative (KDOQI) and the Kidney Disease: Improving Global Outcomes (KDIGO) foundation synthesize the evidence base with methodology, grading the quality of the evidence for the busy clinician. Implementation of the current simple and clear evidence-based targets from those clinical practice guidelines would arguably have an effect greater than that of any blockbuster drug in slowing CKD progression and reducing both cardiovascular events and cardiovascular mortality. Patient safety has recently emerged in the medical literature as a critically important aspect of care, particularly for CKD patients with impaired kidney function, in the following domains: prevention of acute kidney injury or avoidance of nephrotoxins, drug prescription practice that considers the level of kidney function, cardiovascular issues, and preservation of veins for anticipated hemodialysis. Systemic approaches to CKD care, using integrated clinical practice guidelines implemented through clinical decision support (CDS) and computerized practitioner order entry in the electronic health record, hold the most promise for the future implementation of evidence-based CKD care.
Keywords
Chronic kidney disease, clinical decision support (CDS), clinical practice guidelines, clinical targets, patient safety, drug safety, blood pressure, hypertension, implementation
Disclosure The author has no conflicts of interest to declare.
Received: October 07, 2011 Accepted October 28, 2011
Correspondence: Joseph A Vassalotti, MD, Nephrology, One Gustave L Levy Place, Box 1243, New York, NY 10029-6574. E: joseph.vassalotti@mssm.edu

“Water, water, every where,
And all the boards did shrink;
Water, water, every where,
Nor any drop to drink.”
–‘Rime of the Ancient Mariner,’ Samuel Taylor Coleridge

Informing chronic kidney disease (CKD) care is limited because of the paucity of randomized controlled trial (RCT) evidence. Strippoli et al. found that, in 12 disciplines of internal medicine, the number of RCTs was lowest for nephrology and highest for cardiology.1 This dearth of kidney disease RCTs in the literature is ironically compounded by the systematic exclusion of patients with CKD and chronic kidney failure from cardiovascular disease trials, the discipline with the most robust RCT data.2 Fortunately, there are CKD clinical practice guidelines that synthesize the available evidence with a well-defined methodology for grading the quality of that evidence.3,4 Yet the simple and clear clinical targets for blood pressure (BP) and glycemic control in CDK, supported by the available evidence, are remarkably challenging to achieve in routine clinical practice.5,6 The implementation of the current evidence-based targets from the clinical practice guidelines would arguably have an effect greater than that of any blockbuster drug in slowing CKD progression and reducing both cardiovascular events and cardiovascular mortality. The scope of this article is limited to individuals with established CKD, excluding prevention of CKD, CKD screening, and treatment of chronic kidney failure with dialysis and kidney transplantation.

Blood Pressure Control

Methods of measuring BP are summarized in Table 1.7 The Joint National Committee7,8 and Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines9 recommend a BP target of <130/80 mmHg in CKD, but whether the evidence from clinical trials supports this BP target remains controversial, as the majority of trials have not achieved it. In fact, a recent systematic review of the literature revealed that only three RCTs achieved a BP of <130/80 mmHg in people with CKD.10

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