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Kidney Week

Abstract: FR-PO250

The Effect of Integrated Care on the Rate of GFR Decline: A Community Hospital Approach

Session Information

Category: CKD (Non-Dialysis)

  • 1902 CKD (Non-Dialysis): Clinical, Outcomes, and Trials


  • Thanachayanont, Teerawat, Bhumirajanagarindra Kidney Institute, Bangkok, Thailand
  • Tungsanga, Kriang, King Chulalong Memorial lHospital, Bangkok, Thailand

Due to limited amount of nephrologists in Thailand, most of CKD patients are taking care by primary care physicians especially in the rural area. To improve the quality of CKD care in the community hospital level, we had designed the integrated care model which composed of 2 main components including hospital-based multidisciplinary team (MDT) and community care network (CCN) at village level. In our previous study, integrated care model was effective in slowing progression of CKD. It is challenging if this model could be implemented in routine practice.


We are conducting a quasi experimental study.Patients aged 18-70 years old with stage 3 or 4 CKD were enrolled from 5 district hospitals. All patients were managed by integrated care teams.Hospital-based MDT provided group education,individual counselling in addition to standard CKD care.CCN team performed individual counseling and monitoring on proper lifestyle modification,protein and salt intake assessment.All patients will have hospital visit every 3 months and will receive home visit by CCN twice a year.


914 stage 3 and 4 CKD patients were enrolled.Mean age was 62+6.13 years. 37.2%,43.7%,19.1% of the cohort were in CKD stage 3A, 3B and 4, respectively. Diabetic kidney disease was the leading cause of CKD. Mean eGFR at baseline were 40.38+10.26 ml/min/1.73 m2. Baseline SBP and DBP were 128+17.07 and 73+10.56 mmHg,respectively. 79.9% of the study cohort had negative proteinuria by urine dipstick.The rate of eGFR change at 1 year of follow-up was – 0.838+10.06 ml/min/year.Patients with baseline BP less than 140/90 mmHg had a slower rate of eGFR decline when compared with patients with baseline BP 140/90 mmHg or more [-0.554+10.53vs-1.62+8.50 ml/min/year;P=0.04]. Patients with baseline proteinuria 1+ or more had greater rate of eGFR decline than those with negative proteinuria [-2.35+11.26vs-0.401+9.77 ml/min/year;P=0.001].


Our study revealed that this integrated care model has a beneficial effect on slowing the rate of eGFR decline in CKD stage 3-4 patients.Baseline BP and degree of proteinuria are 2 main factors that were significantly associated with greater rate of eGFR decline. Our study shows that the integrated care model could be successfully implemented at the community hospital level. It seems promising this integrated care could be implemented in another developing countries.


  • Private Foundation Support