Chronic Kidney Disease in Primary Care

Duaine D. Murphree, MD; Sarah M. Thelen, MD

Disclosures

J Am Board Fam Med. 2010;23(4):542-550. 

In This Article

Abstract and Introduction

Abstract

Because chronic kidney disease is a growing health concern, family physicians must be equipped to care for this unique patient population. Diabetes mellitus and hypertension, which are commonly addressed in the office setting, are the largest contributors to chronic kidney disease; therefore, these risk factors should be tightly controlled and these patients should be screened closely for signs of renal damage. The National Kidney Foundation recommends that screening include determination of the glomerular filtration rate (GFR) and assessment for the presence of proteinuria. Once the diagnosis of chronic kidney disease is established (by the presence of persistent kidney damage or a GFR <60 mL/min/1.73m2 for at least 3 months), the etiology of chronic kidney disease needs to be elucidated. Often the etiology can be determined by history alone; however, reversible causes of chronic kidney disease should be considered in all patients. Regardless of the underlying etiology of the chronic kidney disease, the family physician can make a significant impact in slowing the progression of chronic kidney disease through strict blood pressure control, tight glycemic control, reduction in the degree of proteinuria, and smoking cessation. All chronic kidney disease patients are at significantly increased risk of cardiovascular events; therefore, additional cardiovascular risk factors such as hyperlipidemia should be managed aggressively. Assessment for the complications of chronic kidney disease, including anemia, bone metabolism abnormalities, metabolic acidosis, and malnourishment, should be assessed once the GFR declines below 60 mL/min/1.73m2 (stage 3). Early screening and treatment of these complications can prevent the development of further sequelae and should not be delayed until referral to nephrology. Appropriate counseling and health maintenance is also needed for this patient population and should be given by the family physician involved in the patient's care.

Introduction

The prevention, early detection, and prompt treatment of chronic kidney disease is within the realm of the family physician. It is estimated that 13% of the adult population suffers from chronic kidney disease and the numbers are expected to continue to climb.[1] With this rise in the prevalence of chronic kidney disease, the role of the family physician in improving patient care and disease outcomes has become increasingly evident. In this regard, additional training and education about chronic kidney disease and its complications is warranted to better equip family physicians to directly impact disease progression. It has been shown that primary care physicians' familiarity with chronic kidney disease is suboptimal,[2] and the goal of this article is to provide family physicians with the knowledge required to provide quality care for their patients with chronic kidney disease.

Chronic kidney disease is defined by the National Kidney Foundation[3] as either a decline in glomerular filtration rate (GFR) to <60 mL/min/1.73m2 or the presence of kidney damage for at least 3 months. Signs of kidney damage classically include proteinuria but other markers of damage, such as persistent glomerulonephritis or structural damage from polycystic kidney disease, can also be present. Chronic kidney disease has been subdivided into 5 stages of increasing severity (Table 1). The complications of chronic kidney disease are associated with various stages and the screening recommendations vary by stage. Previous laboratory evaluations of renal function, such as 24-hour urine collections for creatinine clearance, are generally no longer necessary because of the accuracy and ease of the calculation of the GFR from serum laboratory values. The use of serum creatinine is not sufficient for determining chronic kidney disease because approximately half of the renal function must be lost before the creatinine will be elevated out of the normal range.

GFR calculations should be included routinely by laboratories; however, if needed, it can be easily calculated using the Modification of Diet in Renal Disease study calculator. This is the equation that is recommended by that National Kidney Foundation[3] and is available online.[4] The Cockroft-Gault equation is useful for medications that require renal dosing because it is used to calculate creatinine clearance. Neither of these calculations should be used during acute renal failure because a stable creatinine level is required to ensure their accuracy.

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