Chronic kidney disease: appropriateness of therapeutic management and associated factors in the AVENIR study.

RATIONALE, AIMS AND OBJECTIVES The nephrology literature contains little information about the global patterns of medication used in the management of patients with chronic kidney disease (CKD). This study aims to evaluate the appropriateness of nephrological therapeutic management of CKD patients compared with current guidelines and to investigate associations between patient characteristics and the quality of therapeutic management. METHODS All adult CKD patients who were starting dialysis in Lorraine (France) between 1 January 2005 and 31 December 2006 and who had been referred to a nephrologist no less than 1 month previously were enrolled. Demographic, clinical, biological and therapeutic data were collected retrospectively from medical records covering the period from the first nephrology consultation to initiation of dialysis. Outcomes of interest were the appropriateness of the therapeutic management of five aspects of CKD: hypertension/proteinuria, anaemia, bone disease, metabolic acidosis and dyslipidemia. Therapeutic care was given a global rating (high, moderate or poor), depending on the number of aspects being managed appropriately. Relationships between the global rating and demographic and clinical characteristics of patients were explored. RESULTS During predialysis nephrology follow-up, 93.1% of the 420 patients enrolled were receiving antihypertensive therapy; 67.1% were taking a renin-angiotensin system inhibitor. Other prescriptions included: erythropoiesis-stimulating agents (67.4%), iron (48.3%), phosphate binders (38.1%), vitamin D (21.1%), bicarbonates (15.5%) and statins (36.2%). Hypertension/proteinuria was managed appropriately in 72.4% of cases, anaemia in 56.2%, bone disease in 16.7%, metabolic acidosis in 60.2% and dyslipidemia in 61.4%. The global quality of care was high in 22.1% of cases, moderate in 65.7% and poor in 12.2%. After adjustment, the more nephrology consultations a patient had before dialysis, the higher the quality of his or her care. CONCLUSION The quality of therapeutic care delivered to CKD patients in nephrology setting was suboptimal when assessed in terms of adherence to guidelines.