Article

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

ABSTRACT

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

Full-text

Available from: Neil R Powe, Apr 06, 2016
Chronic Kidney Disease in Primary Care: An Opportunity
for Generalists
Delphine S. Tuot, MD, CM
1
and Neil R. Powe, MD
2
1
Division of Nephrology, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA;
2
Department of
Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA.
J Gen Intern Med 26(4):3568
DOI: 10.1007/s11606-011-1650-8
© The Author(s) 2011. This article is published with open access at
Springerlink.com
C
hronic kidney disease (CKD) is a public health concern
affecting nearly 26 million Americans.
1
However, unlike
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 aggressiv ely treated by
primary care providers (PCP).
2,3
In 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.
4
More recent studies
have corroborated these findings
5
and also linked CKD to
increased rates of disability,
6,7
poorer quality of life,
6
greater
cognitive decline,
8
and an increased number of infections.
9
Importantly, there is now strong evidence that medical thera-
pies can alter the course of disease.
10
Providers can slow
progression of CKD to end-stage renal disease (ESRD) with
good blood pressure control (particularly among those with
macroalbuminuria),
11
tighter glycemic control,
12
decreased
albuminuria through the use of angiotensin converting en-
zyme inhibitors (ACEI) or angiotensin receptor blockers
(ARB),
13
and by limiting the use of nephrotoxic medications
such as non-steroidal anti-inflammatory agents.
14
Emerging
therapies such as daily administration of oral sodium bicar-
bonate also show promise.
15
Less 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 C o-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 earlie r 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.
19
and Allen et al.
20
highlight the importance of CKD care to modify health
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 ris k 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 <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
individuals at the highest risk of ESRD, Dalrymple and colleagues
do underscore the importance of identifying CKD in the elderly, as
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
US is lacking. In Dalrymple et al.s study population, self-reported
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.
22
Studies 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,
23
glycemic control is not routinely optimized,
24
and
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 pra ctice 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. Cardiovascular risk reduction in their population was
also suboptimal; nearly three-quarters of patients had annual
lipid testing, but only 44% achieved an LDL<100 mg/dl, the
recommended target. Perhaps even more concerning, over 25% of
patients were prescribed one or more inappropriate medications
Published online February 26, 2011
356
Page 1
for their level of kidney dysfunction. Reassuringly, achievement of
guideline-concordant CKD care was greater among individuals
with higher risks of CKD-associated morbidity and mortality than
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
those in the US. Minorities represent a larger proportion of the US
population than in this study, and they, as well as the poor, are at
highest risk for ESRD.
26
Therefore, 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 care in the US. On the other hand, the affluence
and enhanced multidisciplinary coordination of the health care
system in Massachusetts and the very high percentage of insured
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 P CPs 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 in volvement 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 la ck of e ducation 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.
2730
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
inte rnists and pharmacists and co-management involving
internists and neph rologists 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 Dise ase Educa tion Pr ogram 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 nations 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
(e-mail: npowe@medsfgh.ucsf.edu).
REFERENCES
1. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney
disease in the United States. JAMA. 2007;298(17):2038-47.
2. Boulware LE, Troll MU, Jaar BG, Myers DI, Powe NR. Identification
and referral of patients with progressive CKD: a national study. Am J
Kidney Dis. 2006;48(2):192-204.
3. Guessous I, McClellan W, Vupputuri S, Wasse H. Low documentation of
chronic kidney disease among high-risk patients in a managed care
population: a retrospective cohort study. BMC Nephrol. 2009;10(1):25.
4. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney
disease and the risks of death, cardiovascular events, and hospitaliza-
tion. N Engl J Med. 2004;351(13):1296-305.
5. Tonelli M, Wiebe N, Culleton B, et al. Chronic kidney disease and
mortality risk: a systematic review. J Am Soc Nephrol. 2006;17(7):2034-47.
6. Gorodetskaya I, Zenios S, McCulloch CE, et al. Health-related quality
of life and estimates of utility in chronic kidney disease. Kidney Int.
2005;68(6):2801-8.
7. Plantinga LC, Johansen K, Crews DC, et al. Association of CKD With
Disability in the United States. Am J Kidney Dis. 2011;57(2):212-7.
8. Kurella Tamura M, Wadley V, Yaffe K, et al. Kidney function and
cognitive impairment in US adults: the Reasons for Geographic and
Racial Differences in Stroke (REGARDS) Study. Am J Kidney Dis.
2008;52(2):227-34.
9. James MT, Quan H, Tonelli M, et al. CKD and risk of hospitalization
and death with pneumonia. Am J Kidney Dis. 2009;54(1):24-32.
10. Sarnak MJ, Levey AS, Schoolwerth AC, et al. Kidney disease as a risk
factor for development of cardiovascular disease: a statement from the
Amer ican Heart Association Councils on Kidney in Cardiovascular
Disease, High Blood Pressure Research, Clinical Cardiology, and Epide-
miology and Prevention. Hypertension. 2003;42(5):1050-65.
11. Sarnak MJ, Greene T, Wang X, et al. The effect of a lower target blood
pressure on the progression of kidney disease: long-term follow-up of the
modification of diet in renal disease study. Ann Intern Med. 2005;142
(5):342-51.
12. Patel A, MacMahon S, Chalmers J, et al. Intensive blood glucose
control and vascular outcomes in patients with type 2 diabetes. N Engl J
Med. 2008;358(24):2560-72.
13. Patel A, MacMahon S, Chalmers J, et al. Effects of a fixed combination
of perindopril and indapamide on macrovascular and microvascular
outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a
randomised controlled trial. Lancet. 2007;370(9590):829-40.
14. Gooch K, Culleton BF, Manns BJ, et al. NSAID use and progression of
chronic kidney disease. Am J Med. 2007;120(3):280 e1-7.
15. Mahajan A, Simoni J, Sheather SJ, Broglio KR, Rajab MH, Wesson
DE. Daily oral sodium bicarbonate preserves glomerular filtration rate by
slowing its decline in early hypertensive nephropathy . Kidney Int. 78(3):303-9.
16. Navaneethan SD, Pansini F, Perkovic V, et al. HMG CoA reductase
inhibitors (statins) for people with chronic kidney disease not requiring
dialysis. Cochrane Database Syst Rev. 2009(2):CD007784.
17. Martinez-Ramirez HR, Jalomo-Martinez B, Cortes-Sanabria L, et al.
Renal function preservation in type 2 diabetes mellitus patients with early
357Tuot and Powe: Chronic Kidney Disease in Primary CareJGIM
Page 2
nephropathy: a comparative prospective cohort study between primary
health care doctors and a nephrologist. Am J Kidney Dis. 2006;47(1):78-87.
18. Kinchen KS, Sadler J, Fink N, et al. The timing of specialist evaluation
in chronic kidney disease and mortality. Ann Intern Med. 2002;137
(6):479-86.
19. Dalrymple LS, Katz R, Kestenbaum B, et al. Chronic kidney disease
and the risk of end-stage renal disease versus death. J Gen Intern Med.
doi:10.1007/s11606-010-1511-x
20. Allen AS, Forman JP, Orav EJ, Bates DW, Denker BM, Sequist TD.
Primary care management of chronic kidney disease. J Gen Intern Med.
doi:10.1007/s11606-010-1523-6
21. OHare AM, Choi AI, Bertenthal D, et al. Age affects outcomes in
chronic kidney disease. J Am Soc Nephrol. 2007;18(10):2758-65.0
22. Peralta CA, Hicks LS, Chertow GM, et al. Control of hypertension in
adults with chronic kidney disease in the United States. Hypertension.
2005;45(6):1119-24.
23. Plantinga LC, Miller ER, 3rd, Stevens LA, et al. Blood pressure control
among persons without and with chronic kidney disease: US trends and
risk factors 1999-2006. Hypertension. 2009;54(1):47-56.
24. Tuot DS, Plantinga L, Hsu C-y, Powe NR. Is awareness of chronic
kidney disease associated with greater achievement of evidence-based
medical therapies? J Am Soc Nephrol. 2010;21:132A.
25. Plantinga L, Grubbs V, Hsu C-y, et al. Hi gh non-steroidal anti-
inflammatory drug use among persons with chronic kidney disease in
the U.S. J Am Soc Nephrol. 2010;21:665A.
26. Volkova N, McClellan W, Klein M, et al. Neighborhood poverty and
racial differences in ESRD incidence. J Am Soc Nephrol. 2008;19
(2):356-64.
27. Greer RC, Cooper LA, Crews DC, Powe NR, Boulware LE. Quality of
patient-physician discussions about CKD in primary care: A cross-
sectional study. Am J Kidney Dis. 2010 [Epub ahead of print]
28. Plantinga LC, Tuot DS, Powe NR. Awareness of chronic kidney disease
among patients and providers. Adv Chronic Kidney Dis. 17(3):225-
36.
29. Diamantidis CJ, Powe NR, Jaar BG, Greer RC, Troll MU, Boulware LE.
Primary care-specialist collaboration in the care of patients with chronic
kidney disease. Clin J Am Soc Nephrol. 2011 [Epub ahead of print]
30. Greer RC, Powe NR, Jaar BG, Troll MU, Boulware LE. Effect of primary
care physicians use of estimated glomerular filtration rate on the timing
of their subspecialty referral decisions. BMC Nephrol. 2011;12(1):1.
[Epub ahead of print]
31. Saran R, Hedgeman E, Plantinga L, et al. Establishing a national
chronic kidney disease surveillance system for the United States. Clin J
Am Soc Nephrol. 5(1):152-61.
358 Tuot and Powe: Chronic Kidney Disease in Primary Care JGIM
Page 3
  • Source
    • "Despite scientific advances that can delay CKD decline and decrease CKD-associated morbidity and mortality, and incorporation of these advances into national [43] and international [44] guidelines, delivery of guideline concordant CKD care remains elusive for many kidney disease patients [45, 46]. This is particularly true among patients who receive care in safety-net settings, where translation of evidence into practice is often impeded by low patient awareness of CKD, poor patient engagement in care, competing clinical demands, and an inefficient health care delivery system [47]. "
    [Show abstract] [Hide abstract] 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: ClinicalTrials.gov, number: NCT01530958.
    Full-text · Article · Oct 2015 · BMC Nephrology
  • [Show abstract] [Hide abstract] 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.
    No preview · Article · Dec 2012 · Journal of Renal Care
  • [Show abstract] [Hide abstract] ABSTRACT: Much of the medical literature on patient compliance explores why patients fail to follow practitioners’ instructions. This paper explores perspectives on ‘compliance’ expressed in online discussion groups for kidney patients. Discourse analysis was used to investigate how contributors conceptualise knowledge and the role of the renal patient. In the discussion groups, patients were sometimes seen to have better understanding of the details of their illness than some practitioners, a focus born of inhabiting their situation and therefore having more at stake. Some patients set themselves the task of supervising their own care, double checking the work of practitioners. This did not threaten biomedical knowledge, but these counter-discourses challenge professional boundaries by making it the prerogative of patients to obtain biomedical knowledge. I explore issues of surveillance and frustration, and the potential usefulness of patients’ overseeing their own safety, while flagging the potential plight of less ‘empowered’ or motivated patients.
    No preview · Article · Mar 2013 · Health Sociology Review
Show more