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Five-year outcomes of a holistic programme for managing early chronic kidney disease in primary care
Sky Wei Chee Koh1, Ping Young Ang1,2, Hung Chew Wong3
1National University Polyclinics, National University Health System, Singapore.
Insights
Maintaining angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB) dosage is crucial for slowing chronic kidney disease (CKD) progression. Early CKD patients on reduced or stopped ACEi/ARB doses progressed faster to advanced kidney disease.
Area of Science:
- Nephrology
- Public Health
- Clinical Research
Background:
- The Holistic Approach in Lowering and Tracking Chronic Kidney Disease (HALT-CKD) program was established in Singapore in 2017 to address the rising prevalence of chronic kidney disease (CKD).
- Early detection and management of CKD are critical to prevent disease progression and reduce associated morbidity.
Purpose of the Study:
- To evaluate the effectiveness of the HALT-CKD program in managing early-stage CKD patients.
- To identify key factors associated with the progression of CKD in a real-world, nationwide setting.
Main Methods:
- A retrospective cohort study was conducted involving 3800 adult patients (CKD stages G1-G3A) recruited from Singapore polyclinics between 2017 and 2018.
- Progression to advanced CKD (G3B-G5) was monitored until March 2023 using serum creatinine levels, with descriptive statistics and Cox regression analysis employed.
- Patients were censored if they transferred care, passed away, or defaulted without disease progression.
Main Results:
- Over a median follow-up of 4.7 years, 12.6% of patients progressed to advanced CKD, despite improvements in HbA1c, blood pressure, and albuminuria.
- Factors significantly accelerating CKD progression included increasing age, female sex, baseline creatinine, diastolic blood pressure, HbA1c, and the presence of macro-albuminuria.
- Reduced or discontinued use of angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB) was associated with faster progression (HR 1.92), while counselling and SGLT2i use did not show significant protective effects.
Conclusions:
- Maintaining optimal dosage of ACEi/ARB is vital for delaying CKD progression, and premature cessation should be avoided.
- Further investigation is warranted into the roles of patient counselling and sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapy in managing early CKD.
- The findings highlight the importance of medication adherence and management strategies in mitigating the progression of chronic kidney disease.
Introduction:
Holistic Approach in Lowering and Tracking Chronic Kidney Disease (HALT-CKD) is a nationwide programme that was introduced in 2017 to combat CKD in Singapore. This study aims to evaluate outcomes of the HALT-CKD programme and identify factors influencing disease progression among early CKD patients.
Method:
We conducted a retrospective cohort study involving adult patients aged 21 to 80 with CKD stages G1-G3A, recruited from 5 Singapore polyclinics between 2017 and 2018. The primary outcome-time to progression to advanced CKD (G3B-G5)-was tracked until March 2023, based on patients' last known serum creatinine levels. Descriptive statistics and Cox regression were used. Patients who followed up with other institutions, were deceased or defaulted without developing (or experiencing) the outcome were censored.
Results:
We studied 3800 patients (mean age: 61.9 years) for a median of 4.7 years. Among them, 12.6% developed advanced CKD despite statistically significant improvements in HbA1c, blood pressure and albuminuria levels. Increasing age, female sex, clinic, baseline creatinine, diastolic blood pressure and HbA1c significantly shortened time to CKD progression. Macro-albuminuria at baseline (hazard ratio [HR] 1.77, 95% confidence interval [CI] 1.19- 2.61) and at analysis (HR 2.22, 95% CI 1.55-3.19) significantly accelerated advanced CKD progression. Patients who had their angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB) dose reduced or discontinued progressed to advanced CKD earlier (HR 1.92, 95% CI 1.50-2.45). Counselling and sodium-glucose cotransporter-2 inhibitor (SGLT2i) use did not significantly delay CKD progression.
Conclusion:
Maintaining optimal ACEi/ARB dosage is essential to delay CKD progression. Premature cessation or reduction of this dosage should be discouraged. Further research on counselling and SGLT2i use in early CKD is needed to address the growing burden of CKD.
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