Chronic Kidney Disease:
Primary Care Management and When to
Refer to a Nephrologist:
What is Chronic Kidney
Disease?
The presence of markers of
kidney damage for ≥3 months, as defined by structural or functional
abnormalities of the kidney with or without decreased GFR, manifest by either pathological abnormalities or other markers of
kidney damage, including abnormalities in imaging tests or blood or urine
tests.
OR
The presence of GFR <60 mL/min/1.73 m2 for ≥3 months, with or without
other signs of kidney damage as described above.
•Based on these definitions, the recommended
classification of Chronic Renal Disease by stage is:
•Stage
1 – Normal GFR (>90 mL/min) AND persistent albuminuria
•Stage
2 – GFR 60-89 AND persistent albuminuria
•Stage
3 - GFR 30-59
•Stage
4 – GFR 15-29
•Stage
5 – GFR <15 OR ESRD
•Issues
involved in the Management of Chronic Kidney Disease:
•
Treatment of
reversible causes of renal dysfunction.
•
Preventing or
slowing the progression of renal disease.
•
Treatment of the
complications of renal dysfunction.
•
Identification
and adequate preparation of the patient in whom renal replacement therapy will
be required.
Complications
of renal dysfunction:
•
Volume overload
•
Hyperkalemia
•
Metabolic
Acidosis
•
Hyperphosphatemia
•
Renal Osteodystrophy
•
Hypertension
•
Anemia
•
Dyslipidemia
•
Sexual
Dysfunction
Referral to Nephrologists
•Some studies suggest that pts with CKD should be
referred to nephrologists early in the course of their disease, preferably
before the plasma creatinine exceeds 1.2 and 1.5 in
women and men, respectively, or the estimated GFR <60.
•K/DOQI recommendations are that pts with CKD be
referred to a specialist for consultation and comanagement
if the clinical action plan cannot be prepared, the prescribed evaluation of
the pt cannot be carried out, or the recommended treatment cannot be carried
out. In general, pts with a GFR <30mL/min/1.73m2 should be referred to a nephrologist.
•Reasons to refer:
1) Improved management of
issues related to CKD (including treatment of anemia, bone disease, etc).
2) Dietary education
3)Counseling about choice of
renal replacement therapy
4)Preparation for hemodialysis
•Early referral enables
dialysis to be initiated at the optimal time with a functioning chronic access
and may also permit recruitment of family members for the placement of a renal
allograft prior to the need for dialysis.
Conclusions:
•
Chronic Kidney
Disease is a complex process that involves management of issues on both the
primary care level and sub-specialty level.
•
Estimation of GFR will aid with classification into the different stages, and guidelines
then help direct treatment of the multiple complications associated with renal
dysfunction based on the pt’s stage.
•
Understand the
importance is managing complications to help slow the progression of renal
disease and improve the pt survival.
•
Recognize that
early nephrology referral is important in improving patient outcome.