title: Influence of Nephrologist Care on Management and Outcomes in Adults with Chronic Kidney Disease.
abstract: BACKGROUND
  Predialysis nephrology care for adults with late stage chronic kidney disease (CKD) is associated with improved outcomes. Less is known about the effects of nephrology care in earlier stages of CKD.
  
  
  OBJECTIVE
  We aimed to evaluate the effect of nephrology care on management of CKD risk factors and complications, CKD progression, incident cardiovascular disease (CVD), and death.
  
  
  METHODS
  This was a prospective cohort study.
  
  
  METHODS
  Participants included 3855 men and women aged 21 to 74 years enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study with a mean (SD) estimated glomerular filtration rate (eGFR) at entry of 45 (17) ml/min/1.73 m(2), followed for a median of 6.6 years.
  
  
  METHODS
  The main predictor was self-reported prior contact with a nephrologist at study enrollment. Outcomes evaluated included CKD progression (≥ 50 % eGFR loss or end-stage renal disease), incident CVD, and death.
  
  
  RESULTS
  Two-thirds (67 %) of the participants reported prior contact with a nephrologist at study enrollment. They were younger, more likely to be male, non-Hispanic white, and had lower eGFR and higher urine protein (p < 0.05). A subgroup with eGFR 30- < 60 ml/min/1.73 m(2) and prior contact with a nephrologist were more likely to receive pharmacologic treatment for CKD-related complications and to report angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use. After propensity score matching (for reporting prior contact with a nephrologist vs. not) and adjusting for demographic and clinical variables, prior contact with a nephrologist was not significantly associated with CKD progression, incident CVD or death (p > 0.05).
  
  
  CONCLUSIONS
  One-third of CRIC participants had not seen a nephrologist before enrollment, and this prior contact was subject to age, sex, and ethnic-related disparities. While prior nephrology care was associated with more frequent treatment of CKD complications and use of ACEi/ARB medications, there was neither an association between this care and achievement of guideline-recommended intermediate measures, nor long-term adverse outcomes.
authors.affiliation: Department of Medicine, Division of Nephrology, University of Illinois at Chicago, 820 South Wood Street, 418W CSN, M/C 793, Chicago, IL, 60612-7315, USA. aricar2@uic.edu.
authors.forename: Ana C
authors.initials: AC
authors.lastname: Ricardo
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Roy
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Kaixiang
authors.initials: K
authors.lastname: Tao
authors.affiliation: Department of Medicine, Tulane University, New Orleans, LA, USA.
authors.forename: Arnold
authors.initials: A
authors.lastname: Alper
authors.affiliation: Department of Medicine, Tulane University, New Orleans, LA, USA.
authors.forename: Jing
authors.initials: J
authors.lastname: Chen
authors.affiliation: Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Drawz
authors.affiliation: Department of Medicine, University of Maryland, Baltimore, MD, USA.
authors.forename: Jeffrey C
authors.initials: JC
authors.lastname: Fink
authors.affiliation: Department of Medicine, University of California, San Francisco, CA, USA.
authors.forename: Chi-Yuan
authors.initials: CY
authors.lastname: Hsu
authors.affiliation: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
authors.forename: John W
authors.initials: JW
authors.lastname: Kusek
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Akinlolu
authors.initials: A
authors.lastname: Ojo
authors.affiliation: Department of Nephrology and Hypertension, Cleveland Clinic Foundation, Cleveland, OH, USA.
authors.forename: Martin
authors.initials: M
authors.lastname: Schreiber
authors.affiliation: Center of Innovation for Complex Chronic Healthcare, Jesse Brown VA Medical Center, Chicago, IL, USA.|Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Fischer
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence; D019468:Disease Management; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D005919:Glomerular Filtration Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000379:methods*; D017063:Outcome Assessment, Health Care / Q000379:methods*; D011446:Prospective Studies; D012017:Referral and Consultation; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis* / Q000628:therapy*; D012307:Risk Factors; D013997:Time Factors; D055815:Young Adult
keywords: chronic kidney disease; nephrology care; outcomes