Examine the optimal multidisciplinary care teams for patients with chronic kidney disease from a nationwide cohort study

Abstract

Background: Multidisciplinary team-based integrated care (MDC) has been recommended for patients with chronic kidney disease (CKD). However, team-based specific structured care systems are not yet established. Therefore, we investigated the efficacy of MDC system and the optimal number of professionals that make up the team for maintaining kidney function and improving prognosis.

Methods: This nationwide, multicenter, observational study included 2,957 Japanese patients with CKD who received MDC from 2015 to 2019. The patients were divided into four groups according to the number of professionals in the MDC team. Groups A, B, C, and D included nephrologists and one, two, three, and four or more other professionals, respectively. Changes in the annual decline in estimated glomerular filtration rate before and after MDC were evaluated. Cox regression was utilized to estimate the correlation between each group and all-cause mortality and the start of renal replacement therapy (RRT) for 7 years.

Results: The change in eGFR significantly improved between before and at 6, 12, and 24 months after MDC in all groups (all p < 0.0001). Comparing group D to group A (reference), the hazard ratio (HR) for all-cause mortality and the start of the RRT was 0.60 (95% confidence interval, 0.48-0.73; p < 0.0001) after adjustment for multiple confounders. Lower HR in group D was confirmed in both diabetes and nondiabetes subgroups.

Conclusion: An MDC team comprised of five or more professionals might be associated with improvements in mortality and kidney prognosis. Furthermore, MDC might be effective for treating CKD other than diabetes.

Keywords: Certified kidney disease educator; Chronic kidney disease; Estimated glomerular filtration rate; Kidney function; Multidisciplinary care; Renal replacement therapy.

Figure 1.. Flowchart of study participants.

CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate.

Figure 2.. Annual changes in eGFR decline (ΔeGFR) in the 12 months before and 24 months after initiation of MDC.

(A) Group A, (B) group B, (C) group C, and (D) group D. Data are shown as the mean. Bars indicate the 95% confidence interval. ^*p < 0.0001 vs. before the start of MDC. eGFR, estimated glomerular filtration rate; MDC, multidisciplinary care.

Figure 3.. Changes in urinary protein levels between the time of initiation of MDC and 24 months after initiation of MDC.

(A) Group A, (B) group B, (C) group C, and (D) group D. Data are shown as the median and interquartile range. ^***p < 0.0001, ^**p < 0.001, ^*p < 0.01 vs. baseline. MDC, multidisciplinary care; UPCR, urinary protein to creatinine ratio.

Figure 4.. Japanese chronic kidney disease patients’ Kaplan-Meier curves for the occurrence of all-cause mortality and the start of renal replacement therapy in four groups according to the number of professionals consisting of the multidisciplinary care team.

Group A vs. group B, p = 0.30; group A vs. group C, p = 0.41; group A vs. group D, p < 0.0001; group B vs. group C, p = 0.054; group B vs. group D, p < 0.0001; group C vs. group D, p < 0.0001.

Figure 5.. Kaplan-Meier curves for the incidence of all-cause death and the start of renal replacement therapy in these patients.

Japanese chronic kidney disease patients with (A) and without (B) diabetes are divided into four groups based on the number of professionals who make up the multidisciplinary care team. (A) Group A vs. group B, p = 0.002; group A vs. group C, p = 0.78; group A vs. group D, p < 0.0001; group B vs. group C, p = 0.0004; group B vs. group D, p = 0.69; group C vs. group D, p < 0.0001. (B) Group A vs. group B, p = 0.70; group A vs. group C, p = 0.82; group A vs. group D, p = 0.0001; group B vs. group C, p = 0.80; group B vs. group D, p = 0.02; group C vs. group D, p < 0.0001.