Shared care for patients with chronic kidney disease in nephrology and general practice.

A randomized controlled trial will be performed: 9 GP practices will be randomised to control or intervention. Patients with hypertension and/or diabetes mellitus with an estimated glomerular filtration rate < 60 ml/min/1.73 m² (MDRD)will be included in the study with a minimum of 20 and a maximum of 28 patients per practice.

The patients in intervention practices will be monitored:

1. Cardiovascular risk (smoking, blood pressure, cardiovascular co-morbidity);

2. Laboratory: creatinine, ureum, sodium, potassium, calcium, phosphate, Hb, MCV, lipids, fasting glucose, glyHb;

3. Urine: albumin, protein, creatinine;

4. Important co morbidity;

5. Medication;

6. UKPDS or SCORE riskengine score.

After 12 months this monitoring will be repeated.
The intervention patients will be treated by GP and practice nurse according to a shared care model. Patients with a GFR < 30 ml/min/1.73 m² or a GFR between 30 ¨C60 GFR /min/1.73 m² and proteinuria will be presented to a nephrologist by web based consultation.

In control practices of the NMP project patients will receive usual care (according to the diabetes- and cardiovascular risk-guidelines of the Dutch College of General Practitioners).

The hypothesis is that patients with chronic kidney disease will meet treating goals better when they are treated in a shared care model by a general practitioner, a practice nurse and with online consultation of a nephrologist.

Blood sample and blood pressure when included (baseline) and after 12 months.

In intervention practices patients will be treated conform a shared care model by a practice nurse, a GP and a nephrologist. A treatment protocol and web based consultation will be part of this shared care model.

Goals are optimal management of cardiovascular risk.