许多初级保健医生都不熟悉CKD指南

拉斯维加斯—— 一项网络调查显示，略多于一半的初级保健医生（PCPs）称其对于14年前就已公布的非糖尿病性慢性肾病（CKD）指南并不熟悉，但75%都表示愿意改进其对于这类患者的诊疗实践。

美国范德堡大学的Khaled Abdel-Kader博士称，许多非透析依赖性CKD患者都是由PCPs负责诊治的。研究显示，许多CKD患者接受的诊疗服务并不理想。最近，美国国家肾脏基金会对其2000年发布的CKD临床实践指南进行了更新，特别强调了蛋白尿的重要性。

Khaled Abdel-Kader博士

基于美国医学会提供的数据，Abdel-Kader博士及其同事开展了一项针对美国PCPs的横断面网络调查，以评估其对于CKD指南的了解程度、自我报告的实践行为以及落实指南推荐意见所面临的障碍，包括蛋白尿的检测。

共有848名PCPs打开了涉及这项调查的电子邮件，其中165名（19.5%）做出了回复。大部分受访者（88%）至少有一半的时间是在从事临床工作，46%在私人诊所或医院工作。

几乎所有受访者（96%）都认为肾小球滤过率（GFR）数据很有用，分别有75%和91%的受访者认为当非糖尿病高血压患者的GFR估算值（eGFR）大于60 mL/min/1.73 m²或小于60 mL/min/1.73 m²时需要检测蛋白尿。Abdel-Kader博士报告称：“不过，常见障碍包括指南对于患者管理的用处不大、时间有限以及不知道指南推荐开展蛋白尿检测。”

“虽然PCPs对于eGFR明显下降（eGFR小于45 mL/min/1.73 m²）或eGFR下降伴蛋白尿患者的CKD定义高度一致，但当eGFR大于60 mL/min/1.73 m²或患者处于CKD 3a期且不伴蛋白尿时，受访者的意见就没那么统一了。”

大部分受访者（平均78%）都认为血管紧张素转换酶抑制剂（ACEI）和血管紧张素受体阻滞剂（ARB）可以改善CKD患者的结局，但对于重度vs.中度蛋白尿的处理，受访者的观点不太统一（分别为78% vs. 85%；P=0 .03）。

略多于一半（51%）的PCPs称其对CKD指南并不熟悉，但75%都表示愿意接受除CME以外的系统干预以改进其对于CKD患者的诊疗实践。Abdel-Kader博士说：“新版指南强调的一个重点是蛋白尿对于CKD患者的重要性，但许多PCPs可能都还不太清楚蛋白尿检测的价值。”“这可能是高危和低危患者CKD治疗不理想的原因之一。与PCPs一起制定系统的干预措施，在不影响工作流程的前提下简化并改进CKD诊疗实践，这可能会起到很大的作用。”

Abdel-Kader博士指出，这项调查的确也存在一些局限性，比如回复率偏低。“实际接受了调查的PCPs比我们的目标调查人群更年轻，内科医生占的比例更大。”“既往研究表明这些特征可能与CKD指南和推荐意见的熟悉程度更高相关。因此，整个PCP群体对于CKD的认识和指南的熟悉程度可能比我们得到的调查数据还要低。”

该研究发表后，Abdel-Kader博士又在美国国家肾脏基金会组织召开的一次会议上报告了研究结果。他在发言后接受采访时说：“还需要开展更严谨的研究以确定可以克服这些障碍并改进CKD最佳诊疗实践的系统干预措施。”“从我们的调查结果来看，虽然填补知识空白和克服态度方面的障碍仍然重要，许多PCPs也针对CKD患者制定了合理的治疗目标，但还需要通过一些机制来帮助他们以及他们的患者达到这些目标。” （BMC Nephrol. 2014 April 22 [doi:10.1186/1471-2369-15-64]）。

美国天普大学的家庭与社区医学教授Neil Skolnik博士指出，CKD是一个非常重要的主题，累及了超过15%的美国人口。“这是一项很好的研究，就电子邮件调查而言，这样的回复率已经相当高了。这说明PCPs对于CKD患者的临床诊疗很感兴趣。”“这种兴趣也反映在他们的回答中。虽然一半的PCPs对CKD指南不熟悉，但75%都表示愿意改进其对于CKD患者的诊疗实践，所以下一步我们应该关注如何最好地传播指南信息并且为PCPs提供相应的工具以便其最好地实施指南建议。”

该研究由美国国立卫生研究院资助。Abdel-Kader博士声明无相关经济利益冲突。

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LAS VEGAS – Slightly more than half of primary care physicians reported being unfamiliar with 14-year-old guidelines on nondiabetic chronic kidney disease, but 75% said they were willing to improve how they cared for patients with the condition, results from a Web-based survey showed.

Most non–dialysis-dependent chronic kidney disease (CKD) patients are cared for by their primary care physicians (PCPs). Studies suggest many CKD patients receive suboptimal care. Recently, CKD clinical practice guidelines were updated with additional emphasis on albuminuria, according to a report published in advance of its presentation by Dr. Khaled Abdel-Kader at a meeting sponsored by the National Kidney Foundation.

"Rigorous studies are needed to help identify systematic interventions that can overcome identified barriers and improve optimal CKD care delivery," Dr. Abdel-Kader said in an interview following his presentation. "Based on our findings, while overcoming knowledge deficits and attitudinal barriers remains important, many primary care physicians set appropriate care goals in CKD, but systems are needed to help them and their patients achieve these goals," (BMC Nephrol. 2014 April 22 [doi:10.1186/1471-2369-15-64]).

Dr. Neil Skolnik noted that CKD is an incredibly important topic, affecting more than 15% of the U.S. population. "This is an excellent study with a very good response rate for an e-mail survey, indicating that primary care physicians are interested in the care of patients with CKD.

"This interest is reflected in the answers provided on the survey. With half of primary care physicians unfamiliar with the CKD guidelines, and 75% expressing interest in improving their care of patients with CKD, the next step should focus on how to best disseminate information about the guidelines and provide tools for primary care physicians to best implement the guidelines," said Dr. Skolnik, who is professor of family and community medicine at Temple University, Philadelphia.

Dr. Abdel-Kader and his associates used data from the American Medical Association to conduct a cross-sectional, Web-based survey of PCPs in the United States in an effort to explore their understanding of CKD guidelines, self-reported practice behaviors, and barriers to implementing guideline recommendations, including albuminuria testing. The National Kidney Foundation issued its mostrecent update to its guidelines in 2000.

Of the 848 PCPs who opened an e-mail about the study, 165 (19.5%) responded. The majority of respondents (88%) spent at least half of their time in clinical care, and 46% were in private practice, said Dr. Abdel-Kader of the department of medicine at Vanderbilt University in Nashville, Tenn.

Nearly all respondents (96%) felt that glomerular filtration rate (GFR) values were helpful, while 75% and 91% reported testing for albuminuria in nondiabetic hypertensive patients with an estimated GFR (eGFR) of greater than 60 mL/min per 1.73 m2 or less than 60 mL/min per 1.73 m2, respectively. "However, frequent barriers cited included a lack of effect on management, limited time, and the perceived absence of guidelines recommending albuminuria testing," Dr. Abdel-Kader said.

"While PCPs expressed very high agreement with the definition of CKD in patients with marked decrements in eGFR (eGFR less than 45 mL/min per 1.73 m2) or decrements in eGFR coupled with albuminuria, agreement was less robust when eGFR was greater than 60 mL/min per 1.73 m2 or in CKD stage 3a without albuminuria."

Most respondents (an average of 78%) felt that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improved outcomes in patients with CKD, yet agreement was lower with severe vs. moderate albuminuria (78% vs. 85%, respectively; P= .03).

Slightly more than half of primary care physicians (51%) reported being unfamiliar with chronic kidney disease guidelines, yet 75% were receptive to systematic interventions in addition to CME to improve their care of CKD patients. "The importance of albuminuria in CKD has become a point of emphasis in guidelines relatively recently, and its value in CKD may not be clearly understood by many PCPs," Dr. Abdel-Kader said. "This is likely contributing to suboptimal targeting of CKD treatments in high-risk and low-risk patients. Working with PCPs to develop systematic interventions that help streamline and improve CKD care without disrupting work flow may have significant potential to improve CKD patient care."

The survey did have certain limitations, including its low response rate, he said. "Our respondents were younger and more likely to be internists than the PCPs we targeted," he noted. "Prior studies have shown that these characteristics tend to associate with greater familiarity with CKD guidelines and recommendations. Hence, recognition of CKD and guideline familiarity may be lower in the general PCP community than we document in our survey."

The study was supported by the National Institutes of Health. Dr. Abdel-Kader said he had no relevant financial conflicts to disclose.