Five-year outcomes of a holistic programme for managing early chronic kidney disease in primary care.

Introduction: Holistic Approach in Lowering and Tracking Chronic Kidney Disease (HALT-CKD) is a nationwide programme that was introduced in 2017 to combat CKD in Singapore. This study aims to evaluate outcomes of the HALT-CKD programme and identify factors influencing disease progression among early CKD patients.

Method: We conducted a retrospective cohort study involving adult patients aged 21 to 80 with CKD stages G1-G3A, recruited from 5 Singapore polyclinics between 2017 and 2018. The primary outcome-time to progression to advanced CKD (G3B-G5)-was tracked until March 2023, based on patients' last known serum creatinine levels. Descriptive statistics and Cox regression were used. Patients who followed up with other institutions, were deceased or defaulted without developing (or experiencing) the outcome were censored.

Results: We studied 3800 patients (mean age: 61.9 years) for a median of 4.7 years. Among them, 12.6% developed advanced CKD despite statistically significant improvements in HbA1c, blood pressure and albuminuria levels. Increasing age, female sex, clinic, baseline creatinine, diastolic blood pressure and HbA1c significantly shortened time to CKD progression. Macro-albuminuria at baseline (hazard ratio [HR] 1.77, 95% confidence interval [CI] 1.19- 2.61) and at analysis (HR 2.22, 95% CI 1.55-3.19) significantly accelerated advanced CKD progression. Patients who had their angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB) dose reduced or discontinued progressed to advanced CKD earlier (HR 1.92, 95% CI 1.50-2.45). Counselling and sodium-glucose cotransporter-2 inhibitor (SGLT2i) use did not significantly delay CKD progression.

Conclusion: Maintaining optimal ACEi/ARB dosage is essential to delay CKD progression. Premature cessation or reduction of this dosage should be discouraged. Further research on counselling and SGLT2i use in early CKD is needed to address the growing burden of CKD.