Chronic Kidney Disease in Primary Care: An Opportunity
Delphine S. Tuot, MD, CM1and Neil R. Powe, MD2
1Division of Nephrology, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA;2Department of
Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA.
J Gen Intern Med 26(4):356–8
© The Author(s) 2011. This article is published with open access at
other chronic conditions with a similarly large prevalence in
the US (e.g., hypertension, diabetes mellitus, and chronic
obstructive pulmonary disease) and despite the association
between CKD and morbidity and mortality, CKD has been
largely under-recognized and not aggressively treated by
primary care providers (PCP).2,3In a landmark paper in
2004, Go et al. demonstrated a strong graded association
between worsening kidney function and risk of hospitaliza-
tions, cardiovascular events, and death.4More recent studies
have corroborated these findings5and also linked CKD to
increased rates of disability,6,7poorer quality of life,6greater
cognitive decline,8and an increased number of infections.9
Importantly, there is now strong evidence that medical thera-
pies can alter the course of disease.10Providers can slow
progression of CKD to end-stage renal disease (ESRD) with
good blood pressure control (particularly among those with
macroalbuminuria),11tighter glycemic control,12decreased
albuminuria through the use of angiotensin converting en-
zyme inhibitors (ACEI) or angiotensin receptor blockers
(ARB),13and by limiting the use of nephrotoxic medications
such as non-steroidal anti-inflammatory agents.14Emerging
therapies such as daily administration of oral sodium bicar-
bonate also show promise.15Less strong evidence suggests
that providers can also modify the high morality rate associ-
ated with CKD via similar mechanisms, including blood
pressure control and use of ACEI/ARBs and HMG Co-A
reductase inhibitors for cardiovascular risk reduction.13,16
Given the large problem at hand and the availability of good
therapies to modify the disease course, the importance of CKD
recognition and aggressive management at earlier stages
cannot be underestimated. And given the undersupply of
nephrologists in the US and paucity of referrals to them,17,18
PCPs represent the first line of CKD care. This includes
screening patients at high risk of CKD, identifying CKD, and
managing early stage disease, including its clinical manifesta-
tions, with nephrology assistance when appropriate.
In this issue of JGIM, Dalrymple et al.19and Allen et al.20
highlight the importance of CKD care to modify health
hronic kidney disease (CKD) is a public health concern
affecting nearly 26 million Americans.1However, unlike
outcomes and provide some insight into PCP management of
CKD. Using the Cardiovascular Health Study, Dalrymple and
colleagues compare the overall risk and risk factors of ESRD,
cardiovascular death, and non-cardiovascular death among
older (mean age of 75 years) community-dwelling adults with
moderate CKD [median estimated glomerular filtration rate
(eGFR) of 53 ml/min/1.73 m²]. They corroborate previous
evidence that risk of death is much more likely than
progression to ESRD in older adults21and highlight risk
factors associated with all-cause mortality. Modifiable risk
factors include body mass index <24.9 and current tobacco
smoking; non-modifiable but preventable risk factors include
presence of hypertension and/or diabetes and prevalent heart
failure and/or cardiovascular disease.
While their comparative risk model is limited by a lack of data
about proteinuria, thus hampering their ability to discern
those with kidney disease benefit from more aggressive cardio-
vascular risk reduction than their non-CKD counterparts.
This conclusion cannot be overemphasized. Aggressive car-
diovascular risk factor modification among CKD patients in the
use of ACEI/ARB, an evidence-based therapy to improve the
cardiovascular risk profile (and simultaneously decrease the risk
of ESRD), ranged from a mere 10% to 17%. A similar dismal
percentage has been noted previously in other adult popula-
tions.22Studies have also demonstrated poor implementation of
other components of CKD care in non-clinical database popula-
tions and research cohorts. Blood pressure is not often con-
trolled,23glycemic control is not routinely optimized,24and
chronic NSAID use is too frequent.25
Also in this issue, Allen and colleagues expand upon this
theme by confirming the poor adoption of high-quality CKD
care, including cardiovascular risk reduction, in a clinical
setting. In their multi-specialty group practice caring for
predominantly insured patients with moderate CKD (stage 3),
nearly 90% of patients received yearly eGFR testing. Despite
these ample opportunities for PCPs to identify and manage
CKD, only 30% received annual urine protein testing, limiting
providers’ chances to slow CKD progression by minimizing
proteinuria. Indeed, only 75% of patients received ACEI/ARB
therapy, and 54% achieved guideline-concordant blood pres-
sure control, the main therapies that can lead to proteinuria
reduction. Cardiovascularriskreduction in their populationwas
also suboptimal; nearly three-quarters of patients had annual
lipid testing, but only 44% achieved an LDL<100 mg/dl, the
patients were prescribed one or more inappropriate medications
Published online February 26, 2011
guideline-concordant CKD care was greater among individuals
among those with lower risk.
One important point deserves mention. The practice settings
and patients studied by Allen et al. may not be representative of
populationthaninthis study, and they, aswellasthe poor, are at
highest risk for ESRD.26Therefore, the relative lack of socio-
demographic patient diversity, leading to a paucity of high-risk
CKD patients, may underestimate the provision of guideline-
concordant CKD carein the US. Onthe other hand, the affluence
and enhanced multidisciplinary coordination of the health care
patients likely overestimate the quality of care received by the
average US resident with chronic kidney disease.
Despite these limitations, the study results highlight certain
challenges that impede the adoption of high-quality CKD care
by generalist physicians. Poor provider awareness of CKD and
national CKD management guidelines, and poor communica-
tion among PCPs and nephrologists are two formidable
challenges to overcome. Unsurprisingly, in this study, provider
recognition of CKD was associated with greater monitoring of
kidney disease and decreased prescription of inappropriate
medications; nephrology involvement was associated with
improved cardiovascular risk reduction and enhanced treat-
ment of metabolic bone disease. Other barriers that impede the
adoption of high-quality CKD care include the prevalence of
higher profile co-morbid chronic illnesses such as diabetes and
cardiovascular disease, national policies that emphasize acute
care visits over ones that focus on care for chronic medical
conditions, and a lack of funding opportunities for CKD
implementation research. Additional challenges shown in
other studies include lack of education of primary care
physicians in the use of glomerular filtration rate estimating
equations, poor patient-physician communication, and dis-
agreement of generalists and specialists on their respective
roles in CKD management.27–30
It is imperative for future CKD research to focus on the
elimination of these barriers. More effective use of technology to
help providers identify patients with CKD and provision of
enhanced decision support systems to increase the quality of
CKD care in the face of competing comorbid conditions, are
essential to move the field forward. Health care delivery
systems that allow for greater communication between
internists and pharmacists and co-management involving
internists and nephrologists are key to provide targeted,
coordinated, cost-effective care. The creation of sustainable
patient self-management support programs that incorporate
and build upon the patient education tools created by the
National Kidney Disease Education Program and others,
including the National Kidney Foundation, is necessary to
raise general awareness of kidney disease and its complica-
tions and encourage life-style modifications to improve CKD
risk profiles. Finally, a system of national surveillance for CKD,
now underway, is essential to track the nation’s progress in
improving CKD care.31
The publication of these two articles underscores the impor-
tance of primary care providers in the care of patients with CKD.
The opportunity to further engage generalists, educators, and
researchers is now. It is time to design and implement interven-
tions that increase recognition of CKD, facilitate delivery of high-
quality, coordinated CKD care, and improve health outcomes for
the growing number of patients affected by the CKD epidemic.
Primary care physicians can rise to this challenge.
Grant Support: Dr. Tuot is supported by an American Kidney Fund
Clinical Scientist. Grant. Dr. Powe is supported by grant K24DK02643
from the National Institute of Diabetes and Digestive and Kidney
Diseases, Bethesda, MD.
Open Access: This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
Corresponding Author: Neil R. Powe, MD; Department of Medicine,
San Francisco General Hospital, University of California San
Francisco, 1001 Potrero Ave, 5F38, San Francisco, CA 94110, USA
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