Managing advanced chronic kidney disease: A primary care guide
ABSTRACTChronic kidney disease (CKD) is a common disorder that requires close collaboration between the primary care physician and nephrologist. Most aspects of early CKD can be managed in the primary care setting with nephrology input. As the disease progresses, many aspects of care should be transitioned to the nephrologist, especially as the patient nears end-stage renal disease, when dialysis and transplantation must be addressed.
KEY POINTS
- Steps to stabilize renal function include blood pressure and diabetes control.
- Patients have a very high risk of cardiovascular disease, and one should try to reduce modifiable risk factors such as hypertension (which is also a risk factor for the progression of CKD) and hyperlipidemia.
- In addition to controlling blood pressure, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers reduce proteinuria, a risk factor for progression of CKD.
- Patients with CKD develop secondary hyperparathyroidism, hyperphosphatemia, and, in advanced CKD, hypocalcemia, all leading to disorders of bone mineral metabolism. Low vitamin D levels should be raised with supplements, and high phosphorus levels should be lowered with dietary restriction and phosphate binders.
Starting dialysis
The appropriate time for starting dialysis remains controversial, especially in elderly patients with multiple comorbid conditions.
The IDEAL study99 found no benefit in starting dialysis at a GFR of 10 to 14 mL/min compared with 5 to 7 mL/min. Thus, there is no single estimated GFR at which dialysis should be started. Rather, the development of early uremic symptoms and the patient’s quality of life should guide this decision.82,83,99–101
Hemodialysis involves three sessions per week, each taking about 4 hours. Evidence suggests that longer sessions or more sessions per week may offer benefits, especially in terms of blood pressure, volume, and dietary management. This has led to an increase in the popularity of home and in-center nocturnal hemodialysis programs across the United States.
Peritoneal dialysis?
Peritoneal dialysis is an excellent choice for patients who are motivated, can care for themselves at home, and have a support system available to assist them if needed. It allows for daily dialysis, less fluid restriction, and less dietary restriction, and it gives the patient an opportunity to stay independent. It also spares the veins in the arms, which may be needed for vascular access later in life if hemodialysis is needed.
Recommendation. We recommend that peritoneal dialysis be offered to any suitable patient who is approaching end-stage renal disease.
A COMPREHENSIVE, COLLABORATIVE APPROACH
Chronic kidney disease is a multisystem disorder, and its management requires a comprehensive approach (Table 3). Early detection and interventions are key to reducing cardiovascular events and progression to kidney failure.
Early referral to a nephrologist and team collaboration between the primary care provider, the nephrologist, and other health care providers are essential. Early in the course of CKD, it may be appropriate for a nephrologist to evaluate the patient and recommend a set of treatment goals. Follow-up may be infrequent or unnecessary.
As CKD progresses, especially as the patient reaches an estimated GFR of 30 mL/min/1.73 m2, the nephrologist will take a more active role in the patient’s care and medical decision-making. In some circumstances, it may even be appropriate for the nephrologist to be the patient’s source of primary care, with the primary care provider as a consultant.
Caring for patients with CKD includes not only strategies to preserve renal function and prolong survival, but also making critical decisions about starting dialysis and about the need for transplantation. Early involvement of a nephrologist and early preparation for end-stage renal disease with preemptive transplantation and arteriovenous fistula placement are associated with better patient outcomes. Key to this is collaboration between the primary care provider and the nephrologist, with levels of responsibility for patient care that adapt to the patient’s degree of renal dysfunction and other comorbidities. Such strategies to select patients for timely nephrology referral may help improve outcomes in this vulnerable population.
