title: Barriers to the successful practice of chronic kidney diseases at the primary health care level; a systematic review.
abstract: BACKGROUND
  Chronic kidney disease (CKD), a major global public health problem, has been recognized as one of the eleven important causes of death. This review explores a wide range of barriers related to patients and health systems involved in controlling the prevalence of CKD at the primary health care level.
  
  
  METHODS
  Electronic databases including PubMed/Medline, Cumulative Index to Nursing and Allied Health (CINAHL), Entrez, British Medical Journal (BMJ), EBSCO host, Cochrane and Google scholar were searched for the data published from 2000 to 2010 using MeSH terms such as 'chronic kidney diseases', 'renal transplantation', 'complications', 'health care services', 'acute renal failure'. After screening 587 abstracts, a total of 10 studies were selected for systematic review. Developed countries such as the United Kingdom, the USA and other European countries were reviewed in order to identify the barriers associated with CKD practice at the primary health care level. The reasons for the failure of services at the primary health care level were categorized. A pre-defined protocol was used for data extraction and content appraisal.
  
  
  RESULTS
  At the primary health care level, the major barriers associated with CKD include the late referral of patients to nephrologists, old age, presence of several co-morbidities, lack of education and awareness among ethnic minorities, difficulty in communication between primary health care professionals, and the shortage of multi-disciplinary care team at dialysis centers. Additionally, factors such as drug-drug interaction during treatment, lack of anemia-management during dialysis, hypertension, and depression in CKD patients also act as important barriers in CKD care at the primary health care level.
  
  
  CONCLUSIONS
  The knowledge and awareness about CKD management is lacking. Therefore, educational intervention is essential for patients as well medical personnel. Also, a multidisciplinary care team is essential for the complex management of CKD due to associated co-morbidities.
authors.affiliation: Department of Medicine, University of Buckingham, Ealing Hospital, NHS Trust, London, UK.
authors.forename: Chaudhary Muhammad
authors.initials: CM
authors.lastname: Junaid Nazar
authors.affiliation: Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, USA.
authors.forename: Tiffany Billmeier
authors.initials: TB
authors.lastname: Kindratt
authors.affiliation: Department of Community Medicine, Nawaz Sharif Medical College, Gujarat, Punjab, Pakistan.
authors.forename: Syed Muhammad Ahtizaz
authors.initials: SM
authors.lastname: Ahmad
authors.affiliation: Department of Rural Health Development Program, Rural Area Development Council, Punjab, Pakistan.
authors.forename: Manzoor
authors.initials: M
authors.lastname: Ahmed
authors.affiliation: Division of Medical Education, Postgraduate Medicine Brighton & Sussex Medical School University of Brighton, Brighton, UK.
authors.forename: John
authors.initials: J
authors.lastname: Anderson
keywords: Chronic kidney disease; Dialysis; Established renal failure; Primary health care; Renal replacement therapy; Renal transplantation