Lowering Blood Pressure Among Hypertensives with Screen-Detected Kidney Disease

描述（由申请人提供）：糖尿病和高血压是与慢性肾脏疾病（CKD）和终末期肾脏疾病（ESRD）相关的最常见疾病。与糖尿病相反，在美国非糖尿病性高血压成人中定期筛查CKD并没有被普遍推荐或实施。绝大多数CKD患者和他们的医生都不知道这种疾病。因此，在非糖尿病成人高血压患者中识别CKD患者是将基于证据的方法转化为临床实践以减轻CKD负担的重要机会。我们之前的工作表明，与单独使用肌酐相比，使用肌酐、胱抑素C和尿白蛋白与肌酐比值检测CKD的“三重标记方法”大大增强了对并发症高风险人群的识别。控制BP仍然是CKD管理的支柱；在临床实践中，由护士和药剂师领导的项目在改善血压控制方面最有效。因此，本建议的目的是评估改善未识别CKD的非糖尿病高血压患者血压控制的策略，我们提出了一项实用的，集群随机临床试验，以改善初级保健中筛查出CKD的非糖尿病高血压成人患者的血压控制。第一个干预将评估护士主导的筛查和教育策略的效果，该策略利用“三重标记”CKD筛查方法，结合患者和提供者教育，与常规护理相比。第二项干预将评估由护士和临床药剂师共同领导的筛查、教育和强化治疗方案，与筛查和教育策略和常规护理相比，是否可以改善CKD高危患者的血压管理。基于初级保健的慢性护理模型，该项目旨在利用现有的多学科团队来改善血压水平并增加肾素-血管紧张素系统（ACE/ARB）抑制剂的适当使用。我们还将使用Reach、有效性、采用、实施和维护（RE-AIM）框架评估这些计划的可行性和实施过程。如果成功，这些干预措施将有助于减轻CKD及其相关并发症的负担。

DESCRIPTION (provided by applicant): Diabetes and hypertension are the most common conditions associated with chronic kidney disease (CKD) and end stage renal disease (ESRD). In contrast to diabetes, regular screening for CKD among non- diabetic hypertensive adults in the U.S. is not universally recommended or implemented. The vast majority of persons with CKD and their providers are unaware of the disease. Therefore, identification of persons with CKD among non-diabetic adults with hypertension represents an important opportunity to translate evidence- based approaches into clinical practice to reduce the burden of CKD. Our prior work has shown that a "triple- marker approach" to detect CKD using creatinine, cystatin C and the urinary albumin-to-creatinine ratio greatly enhanced identification of persons at highest risk for complications, compared with creatinine alone. Control of BP remains the mainstay of CKD management; and programs led by nurses and pharmacists have been the most effective at improving BP control in clinical practice. Therefore, the goal of this proposal is to evaluate to strategies to improve BP control among non-diabetic hypertensive persons with unrecognized CKD, We propose a pragmatic, cluster-randomized clinical trial to improve BP control for non-diabetic, hypertensive adults with screen-detected CKD in primary care. The first intervention will evaluate the efficacy of a nurse-led screen-and-educate strategy that utilizes a "triple-marker" CKD screening approach, coupled with both patient and provider education, compared with usual care. The second intervention will evaluate whether a screen, educate, and intensify treatment program co-led by both a nurse and a clinical pharmacist can improve BP management among persons with highest risk CKD, compared with the screen-and-educate strategy and with usual care. Based on the Chronic Care Model for primary care, this project is specifically designed to leverage an existing multi-disciplinary team to improve BP levels and increase appropriate use of inhibitors of the renin-angiotensin system (ACE/ARB). We will also evaluate the feasibility and process implementation of these programs using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. If successful, these interventions could help to reduce the burden of CKD and its associated complications.