Underdiagnosis of chronic kidney disease (CKD) in the nursing home

Objective: Early diagnosis of chronic kidney disease (CKD) in the elderly allows for the implementation of measures proven to delay progression to dependence on dialysis, reduce risk for cardiac complications, and improve medication management. Given that the National Kidney Foundation (NKF) published stage-based protocols (2002) to delay/prevent outcomes associated with CKD, it is incumbent upon physicians to recognize CKD. The purpose of this study is to explore how frequently elderly nursing home residents who qualify for the diagnosis of CKD using NKF criteria are actually recognized by their physicians as having CKD.

Methods: A retrospective chart review was performed on all long-term elderly residents within a 672-bed facility who had resided there for at least 6 months and whose records included at least two serum creatinine levels drawn at least 90 days apart from each other. Each subject's monthly internist progress notes were reviewed to determine if the subject had received a clinical diagnosis of CKD. Glomerular filtration rates (GFRs) were calculated via the Modified Diet in Renal Disease (MDRD) and Cockgraft-Gault formulas.

Results: 280 subjects cared for by 30 internists were studied. The majority (70%) were women; average patient age was 83.1 years. Of the 71 subjects who had CKD by MDRD criteria, 62.0% had not been diagnosed by their physicians. Of subjects with CKD by Cockgraft-Gault criteria, 82.0% had not been formally diagnosed.

Conclusion: Despite well-established criteria for the diagnosis, CKD remains exceedingly underdetected within the nursing home, placing this community at increased risk for costly, avoidable outcomes.