European Journal of Cardiovascular Medicine

Chronic Kidney Disease (CKD) is a global public health problem that affects millions of people worldwide¹. It is characterized by the gradual loss of kidney function over time, leading to a range of complications, including cardiovascular disease, anemia, bone disorders, and an increased risk of mortality². CKD is often asymptomatic in its early stages, which can result in delayed diagnosis and treatment, further exacerbating disease progression and associated complications³.

The management of CKD poses significant challenges due to its progressive nature and the substantial healthcare resources required as the disease advances⁴. Patients with CKD frequently require ongoing medical care, including frequent hospitalizations, specialist consultations, and medication management, especially as they approach end-stage renal disease (ESRD)⁵. The economic burden of CKD on healthcare systems is substantial, particularly in the later stages of the disease when dialysis or kidney transplantation may become necessary⁶.

Medication adherence is a critical factor in the management of CKD, as it can significantly influence disease progression and patient outcomes⁷. Additionally, the presence of comorbid conditions, such as diabetes and hypertension, can accelerate the decline in kidney function and increase the complexity of treatment. Understanding the patterns of disease progression, healthcare utilization, and the impact of adherence and comorbidities is essential for developing targeted interventions to improve patient outcomes and reduce the burden of CKD.

This longitudinal study aims to provide a comprehensive analysis of disease progression, healthcare utilization patterns, and the role of medication adherence and comorbidities in patients with CKD. By examining these factors over a 36-month period, this study seeks to contribute valuable insights into the management of CKD and highlight areas for potential intervention.

Study Design and Setting

This longitudinal observational study was conducted at Prasad Institute of Medical Sciences, Prasad Hospital, Lucknow. The study spanned from May 2023 to April 2024. The primary objective was to assess the progression of chronic kidney disease (CKD) and analyze healthcare utilization patterns, medication adherence, and the impact of comorbidities on patient outcomes over a 12-month period.

Study Population

A total of 200 CKD patients were recruited for the study. Inclusion criteria included patients aged 18 years and older with a confirmed diagnosis of CKD (Stages 3, 4, or 5) based on estimated glomerular filtration rate (eGFR) measurements. Patients were excluded if they had acute kidney injury, were on dialysis at the time of enrollment, or had a history of kidney transplantation.

Data Collection

Data were collected through patient interviews, medical record reviews, and periodic follow-ups. Demographic information, including age, gender, and baseline CKD stage, was recorded at the time of enrollment. Follow-up visits were scheduled every three months to monitor disease progression, healthcare utilization, and medication adherence.

Disease Progression: CKD stage was assessed at each visit based on eGFR, with progression defined as advancement to a more severe CKD stage.

Healthcare Utilization: Data on hospitalizations, outpatient visits, and specialist consultations were collected through patient records and self-reports.

Medication Adherence: Adherence was assessed using the Morisky Medication Adherence Scale (MMAS-8) during each follow-up visit.

Comorbidities: The presence of comorbid conditions such as diabetes, hypertension, and cardiovascular disease was documented at baseline and monitored throughout the study.

Statistical Analysis

Descriptive statistics were used to summarize demographic data, CKD stage distribution, and healthcare utilization patterns. Chi-square tests were applied to assess the association between medication adherence, comorbidities, and disease progression. Kaplan-Meier survival analysis was employed to evaluate time to progression and mortality. All statistical analyses were performed using SPSS version 25, with a significance level set at p < 0.05.

Ethical Considerations

The study protocol was approved by the Institutional Ethics Committee of Prasad Institute of Medical Sciences, Prasad Hospital, Lucknow. Informed consent was obtained from all participants prior to enrollment, ensuring that they were aware of the study's objectives, procedures, and potential risks. Patient confidentiality was maintained throughout the study, with all data anonymized before analysis.

Demographic Characteristics

The study population consisted of 200 patients diagnosed with chronic kidney disease (CKD). The mean age of the participants was 57.3 years (±10.2 years). The gender distribution was nearly equal, with 102 males (51%) and 98 females (49%). At baseline, 140 patients (70%) were in Stage 3 CKD, 40 patients (20%) were in Stage 4, and 20 patients (10%) were in Stage 5 (Table 1).

Table 1: Demographic Characteristics of the Study Population

Disease Progression

During the 36-month follow-up period, disease progression was observed in 42% of the patients. Specifically, 50 patients (25%) progressed from Stage 3 to Stage 4, 24 patients (12%) progressed from Stage 4 to Stage 5, and 10 patients (5%) advanced from Stage 5 to end-stage renal disease (ESRD). The remaining 116 patients (58%) did not experience any progression of their CKD (Table 2).

Table 2: Disease Progression Over 36 Months

Healthcare Utilization Patterns

The study noted a significant increase in healthcare utilization as CKD advanced. The rate of hospitalizations per patient-year increased from 1.2 in Stage 3 to 2.8 in Stage 5. Similarly, the number of outpatient visits per year rose from 5 in Stage 3 to 10 in Stage 5, with specialist consultations also increasing from 2 per year in Stage 3 to 8 per year in Stage 5 (Table 3).

Table 3: Healthcare Utilization Patterns by CKD Stage

Medication Adherence and Disease Progression

The analysis revealed that medication adherence played a crucial role in disease progression. Patients with high adherence to their prescribed medications exhibited a lower rate of disease progression (30%) compared to those with poor adherence (55%). Additionally, high adherence was associated with fewer hospitalizations (1.5 per patient-year) and a lower incidence of cardiovascular events (10%) compared to poor adherence (Table 4).

Table 4: Medication Adherence and Disease Progression

Mortality and Complications

A total of 18 patients (9%) died during the study period. Mortality rates were significantly higher in patients who had progressed to Stage 5 CKD (55%) compared to those in Stage 3 (1.4%) and Stage 4 (12.5%). Cardiovascular events were the leading cause of death across all stages. The study also observed a higher prevalence of complications such as anemia, hyperkalemia, and metabolic acidosis as CKD progressed, with the highest rates seen in Stage 5 (Table 5).

Table 5: Mortality and Complications by CKD Stage

Impact of Comorbidities

Comorbid conditions, particularly diabetes and hypertension, were prevalent in the study population, affecting 60% and 75% of the patients, respectively. Patients with diabetes showed a higher rate of progression to ESRD (15%) compared to non-diabetic patients. The presence of hypertension was also associated with a higher rate of CKD progression (Table 6).

Table 6: Impact of Comorbidities on CKD Progression

Quality of Life

The quality of life of patients, as measured by the Kidney Disease Quality of Life (KDQOL) scale, declined significantly with advancing CKD. Patients in Stage 3 reported higher scores across all domains, including physical health, emotional well-being, and overall quality of life, compared to those in Stages 4 and 5 (Table 7).

Table 7: Quality of Life Scores by CKD Stage (KDQOL Scale)

This longitudinal study provides valuable insights into the progression of chronic kidney disease (CKD) and its associated healthcare utilization, medication adherence, and the impact of comorbidities in a cohort of 200 patients from Prasad Institute of Medical Sciences, Prasad Hospital, Lucknow. The findings underscore the progressive nature of CKD and the increasing healthcare demands as patients advance through the stages of the disease.

Disease Progression and Healthcare Utilization

The study revealed that 42% of the patients experienced disease progression over the 12-month follow-up period, with a significant number advancing to more severe stages of CKD. This progression was accompanied by a marked increase in healthcare utilization, evidenced by the rise in hospitalizations, outpatient visits, and specialist consultations. These findings align with those of Khan et al⁸., who highlighted the escalating resource demands as CKD worsens. The increasing burden on healthcare systems as CKD progresses emphasizes the need for early intervention strategies aimed at slowing disease progression. Proactive management of patients in the earlier stages of CKD could potentially reduce the frequency of hospitalizations and the need for specialist care, thereby alleviating some of the strain on healthcare resources.

Medication Adherence and Disease Outcomes

One of the key findings of this study is the significant impact of medication adherence on disease progression and patient outcomes. Patients with high adherence to their prescribed medications demonstrated a lower rate of CKD progression and fewer cardiovascular events compared to those with poor adherence. This highlights the critical role of medication adherence in managing CKD and preventing complications, as also observed by Meuleman et al⁹. . The challenge of ensuring medication adherence in CKD patients, particularly those with complex treatment regimens, cannot be overstated. Interventions such as patient education, regular follow-up, and the use of digital health tools to monitor and encourage adherence could be beneficial in improving outcomes for CKD patients¹⁰.

Impact of Comorbidities

The presence of comorbid conditions, particularly diabetes and hypertension, was found to significantly accelerate the progression of CKD. Patients with these comorbidities not only progressed faster to end-stage renal disease (ESRD) but also required more intensive healthcare services. This finding is consistent with the work of Kumar et al¹¹., who identified diabetes and hypertension as major risk factors for CKD progression. Given the high prevalence of these comorbidities in the CKD population, integrated care approaches that address both CKD and its associated conditions are essential. Such approaches could include coordinated management plans that involve multidisciplinary teams, ensuring that all aspects of a patient’s health are considered in their treatment plan¹³.

Mortality and Quality of Life

The mortality rate observed in this study, particularly among patients who progressed to Stage 5 CKD, underscores the severity of the disease in its advanced stages. Cardiovascular events were the leading cause of death, further emphasizing the need for vigilant management of cardiovascular health in CKD patients, as also emphasized by Hannan et al¹⁴.  Additionally, the study documented a significant decline in quality of life as CKD progressed, which is consistent with the findings of Pasea et al¹²., who reported similar outcomes . Efforts to improve quality of life in CKD patients should focus on both clinical management and psychosocial support. Addressing the physical and emotional well-being of patients, particularly in the later stages of CKD, is crucial for improving overall outcomes.

This study demonstrates significant CKD progression in 42% of patients over 12 months, accompanied by increased healthcare utilization. High medication adherence was linked to slower disease progression and fewer cardiovascular events, while comorbidities like diabetes and hypertension accelerated CKD advancement. The results emphasize the importance of early intervention, robust medication adherence, and effective comorbidity management to improve patient outcomes and reduce the healthcare burden. These findings suggest that targeted strategies focusing on early detection, patient education, and integrated care could significantly benefit CKD management.

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