LAUSR

The Japanese Government and the Japanese Society of Nephrology (JSN) have enacted measures against chronic kidney disease (CKD) since 2008. Since then, the number of age-adjusted dialysis initiations has decreased. However, the absolute number has not decreased due to aging of the population. In response, the Japanese Government launched new CKD measures in 2018, with a focus on earlier intervention by nephrologists, utilizing referral criteria from family doctors to nephrologists. The primary goal of the new measures is to decrease the annual number of dialysis initiations nationwide by 10% by 2028. The Japan Kidney Association (JKA), also established in 2018, has appointed representatives in each prefecture to work on CKD measures according to the local requirements in cooperation with the Government, family doctors, and organizations. The large number of family doctors and medical examinations facilities that refer to the hospital in central Tokyo lead to difficulty determining the referral criteria that is used. Therefore, the aim of this study is to formulate new CKD measures in our hospital as one of the JKA representatives of Tokyo. A retrospective survey of medical history was conducted for 104 patients who initiated hemodialysis or peritoneal dialysis at our hospital in 2018. These patients represent approximately 3% of the total number of dialysis initiations in Tokyo, with 33 patients originating from outside Tokyo prefecture. Of the 104 patients, 80 were male with an average age 65.9 years. The primary disease of patients was comprised of 30 with diabetic nephropathy, 25 with renal sclerosis, 16 with chronic glomerulonephritis, 4 with polycystic kidney disease, and 29 from other or unknown diseases. Of the 86 patients whose information was confirmed, 45 patients were referred to nephrologists from 15 departments in our hospital, including 12 from diabetic departments, 7 from urology departments, 4 from cardiovascular departments, 3 from the emergency department, oncology department, and neurology department, and 11 from various other departments. The remaining 41 patients were from outside our hospital (30 from family doctors and 11 from medical examination facilities). Of the 57 patients whose eGFR was confirmed at referral, 21 were referred with eGFR<15, 27 at 15≦eGFR<30, and only 9 were referred at eGFR≧30. Criteria of eGFR<45 or proteinuria≧1+ or 0.5g/gCr is recommended in the 2018 Evidence-based Clinical Practice Guideline for CKD by the JSN. According to the medical history of 104 patients who initiated dialysis at our hospital in 2018, the timing of referral to nephrologists was often later than recommended. Patients were referred to nephrologists from at least 15 departments in our hospital. Therefore, it is important for the referral criteria to be widely disseminated not only among family doctors but also among hospital departments and medical examination facilities. Specifically, in-hospital referrals are considered to be less burdensome for patients than out-of-hospital referrals and are therefore expected to be first-targets for new strategies. In addition, in recent years, the frequency of measurement of sCr and eGFR has increased in medical examinations, where the dissemination of referral criteria becomes even more important. Furthermore, the JSN and the JKA have committed to develop medical staff, including nurses/public health nurses, registered dietitians, and pharmacists, to be certified kidney disease educators who have basic knowledge of CKD. Since these occupations can intervene before referral to nephrologists, they are expected to have a significant effect on CKD measures.