Chronic Kidney Disease in Primary Care: An Opportunity for Generalists

Division of Nephrology, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Ave, 5F38, San Francisco, CA, 94110, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 02/2011; 26(4):356-8. DOI: 10.1007/s11606-011-1650-8
Source: PubMed


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 adults 21 and highlight risk factors associated with all-cause mortality. Modifiable risk factors include body mass index

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    ABSTRACT: Objective: To identify primary care providers’ (PCPs) perceived barriers to educating patients about chronic kidney disease (CKD) during routine clinical visits. Methods: We conducted three focus groups of eighteen PCPs in Baltimore, Maryland (MD), USA. Focus groups began with the presentation of a hypothetical case of a patient with CKD, followed by open-ended questions to assess providers’ perceived barriers to delivering education about CKD. Groups were audiotaped, transcribed and coded independently by two investigators who identified major themes. Results: PCPs reported on several patient, provider and system level barriers contributing to poor education about CKD in primary care that were both common and unique to barriers previously reported in educating patients regarding other chronic diseases. Conclusions: Interventions designed to address barriers to CKD education identified by PCPs could improve the delivery of education about CKD in primary care settings.
    Journal of Renal Care 12/2012; 38(4):174-81. DOI:10.1111/j.1755-6686.2012.00323.x
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    ABSTRACT: Background: Chronic kidney disease (CKD) is common and is associated with excess mortality and morbidity. Better management could slow progression of disease, prevent metabolic complications, and reduce cardiovascular outcomes. Low patient awareness of CKD and ineffective patient-provider communication can impede such efforts. We developed provider and patient-directed interventions that harness health information technology to enhance provider recognition of CKD and delivery of guideline concordant care and augment patient understanding and engagement in CKD care. Methods/design: We report the design and protocol of the Kidney Awareness Registry and Education (KARE) Study, a 2x2 factorial randomized controlled trial that examines the impact of a multi-level intervention on health outcomes among low-income English, Spanish and Cantonese-speaking patients with CKD in a safety net system. The intervention includes: (1) implementation of a primary care electronic CKD registry that notifies practice teams of patients' CKD status and employs a patient profile and quarterly feedback to encourage provision of guideline-concordant care at point-of-care and via outreach; and (2) a language-concordant, culturally-sensitive self-management support program that consists of automated telephone modules, provision of low-literacy written patient-educational materials and telephone health coaching. The primary outcomes of the trial are changes in systolic blood pressure (BP) and the proportion of patients with BP control (≤140/90 mmHg) after one year. Secondary outcomes include patient understanding of CKD, participation in healthy behaviors, and practice team delivery of guideline-concordant CKD care. Discussion: Results from the KARE study will provide data on the feasibility, effectiveness, and acceptability of technology-based interventions that support primary care efforts at improving health outcomes among vulnerable patients with CKD. Trial registration:, number: NCT01530958.
    BMC Nephrology 10/2015; 16(1):166. DOI:10.1186/s12882-015-0168-4 · 1.69 Impact Factor
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    ABSTRACT: Early preparation for renal replacement therapy (RRT) is recommended for patients with advanced chronic kidney disease (CKD), yet many patients initiate RRT urgently and/or are inadequately prepared. We conducted audio-recorded, qualitative, directed telephone interviews of nephrology health care providers (n = 10, nephrologists, physician assistants, and nurses) and primary care physicians (PCPs, n = 4) to identify modifiable challenges to optimal RRT preparation to inform future interventions. We recruited providers from public safety-net hospital-based and community-based nephrology and primary care practices. We asked providers open-ended questions to assess their perceived challenges and their views on the role of PCPs and nephrologist-PCP collaboration in patients’ RRT preparation. Two independent and trained abstractors coded transcribed audio-recorded interviews and identified major themes. Nephrology providers identified several factors contributing to patients’ suboptimal RRT preparation, including health system resources (e.g., limited time for preparation, referral process delays, and poorly integrated nephrology and primary care), provider skills (e.g., their difficulty explaining CKD to patients), and patient attitudes and cultural differences (e.g., their poor understanding and acceptance of their CKD and its treatment options, their low perceived urgency for RRT preparation; their negative perceptions about RRT, lack of trust, or language differences). PCPs desired more involvement in preparation to ensure RRT transitions could be as “smooth as possible”, including providing patients with emotional support, helping patients weigh RRT options, and affirming nephrologist recommendations. Both nephrology providers and PCPs desired improved collaboration, including better information exchange and delineation of roles during the RRT preparation process. Nephrology and primary care providers identified health system resources, provider skills, and patient attitudes and cultural differences as challenges to patients’ optimal RRT preparation. Interventions to improve these factors may improve patients’ preparation and initiation of optimal RRTs.
    BMC Nephrology 12/2015; 16(1). DOI:10.1186/s12882-015-0020-x · 1.69 Impact Factor


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