Is cloud-based technology a promising tool in the integrated care of patients with chronic kidney disease?

Chronic kidney disease (CKD) is one of the most prevalent noncommunicable diseases in Taiwan. Previous studies have provided solid evidence of an association between CKD and the increased risk of death, cardiovascular event and end-stage renal disease. In recent years, albuminuria has also been recognized as another major risk factor for cardiovascular disease and CKD progression. Together, CKD and albuminuria are multiplicatively associated with an increased risk of mortality. Currently, the principle approach to lowering the risk of kidney failure and major cardiovascular event in CKD patients with overt proteinuria is intensive blood pressure (BP) control. The 2012 Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline suggests an appropriate BP control target level is consistently 130/80 mmHg in CKD patients with urine albumin excretion > 300 mg/day, although different targets may be recommended by others. Despite the importance of BP control, in one cohort study, only 26% of CKD patients achieved the BP goal suggested by Joint National Committee 7 guidelines. An extensive Cochrane review concluded that home BP monitoring, coupled with an appointment reminder system may help patients improve blood pressure control. However, the results require further evaluation and most of the trials excluded patients with moderate-to-severe kidney disease. In this issue of the Journal of the Chinese Medical Association, Lin et al report a randomized trial comparing two models of home BP monitoring in hypertensive CKD patients. Forty-eight hypertensive patients were included, each with an estimated glomerular filtration rate < 60 mL/minute/1.73m. Twenty-five patients were randomly assigned to the intervention group, where cloud-based manometers integrated with a physician order entry system were applied. Physicians at least weekly reviewed the BP records of patients in the study, and the patients were recalled to the clinic as needed. The other group of patients in the study used the regular home BP recording sheets and had medical adjustment during routine outpatient visit. During the 6-month study period, BP, serum creatinine (Cr), and the spot urine proteinuriaeCr ratio (UTP/UCr) were assessed at baseline and every 3 months. Several patients were lost in follow-up after the enrollment, such that the final analysis included 18 patients from both groups.