Early Referral for Chronic Kidney Disease: The "Why" and the "How"

In his recent editorial "Putting Guidelines for Chronic Kidney Disease Into Practice" (CONSULTANT, October 2006, page 1295), Dr Gregory Rutecki discussed the results of a study that shows many clinicians fail to follow evidence-based guidelines for the management of chronic kidney disease (CKD), such as when to consult a nephrologist.¹ A sampling of the feedback we received appears below, along with Dr Rutecki's responses. Additional comments appear on www.ConsultantLive.com.

-The Editors

• I read with interest Dr Gregory Rutecki's remarks about the need to implement in our practices the evidence-based guidelines for the care of patients with CKD. In my view, the dilemma is not how to incorporate evidence-based guidelines but knowing what they are. As far as I am aware, there is no concise, coherent, practical, and uniform reference source for such guidelines.

I don't mind playing by the rules, but far too often the medical establishment, the government, insurance companies, your own hospital, and sometimes even your colleagues don't tell you what the rules of the game are. We primary care physicians (PCPs) are out here guessing as best we can.

-James H. Carmack, Jr, MD
 Hendersonville, Tenn

You are right. In contrast to the CKD guidelines that were the focus of this dialogue, many other guidelines are less publicized and are not readily available. A user-friendly source that is triggered appropriately would be helpful. Although for selected guidelines this sort of mechanism is available, for the vast majority it is not. Physicians are doing the best they can; assists in this aspect of practice have not kept pace.

- Gregory W. Rutecki, MD
  Director of Medical Education
 Mount Carmel Health System
 Columbus, Ohio
 Clinical Professor of Medicine
 Ohio State University
 Columbus Clinical Professor of Medicine
 Wright State University
 Dayton, Ohio

• According to Dr Rutecki, early referral to a nephrologist may be associated with improved outcomes in patients with CKD. However, his commentary would have had much more value for readers who are PCPs if he had explained what nephrologists do for patients with CKD and how that benefits the patient.

While most PCPs see the value of a nephrologist when a patient requires dialysis, it is not inherently clear what a nephrologist might do for a 50-year-old woman with hypertension, diabetes, and stage 3 CKD that the PCP cannot do. Such a patient clearly has a defined cause for her CKD and therefore does not need a kidney biopsy. The PCP can order renal ultrasonography to rule out obstruction and can use angiotensin-converting enzyme (ACE) inhibitors and other antihypertensives to lower her blood pressure to below 130/80 mm Hg. The PCP is certainly better trained to control her diabetes than the nephrologist--and is also more likely to make sure she has had pneumococcal and influenza vaccines, tetanus-diphtheria-pertussis booster, colonoscopy, mammogram, Pap smear, and so on.

-Ronald Hirsch, MD
   Elgin, Ill

In 1995, the National Kidney Foundation developed guidelines to reduce mortality among patients undergoing dialysis. It didn't take long to realize that unless aggressive treatment was initiated well before dialysis began, better outcomes would be wishful thinking. Permit me to better justify early referral to nephrologists and discuss a team approach to chronic diseases.

Among the specific interventions for stage 3 CKD that Dr Hirsch mentions are a number of appropriate primary care treatments as well as several critical, specifically "renal" therapies. Where would a nephrologist practicing in accord with CKD quality standards come in?

First, a nephrologist's help with anemia is essential. Patients with CKD who have diabetes have 2 to 3 times more problems in this area than do other patients with CKD. The definitions of anemia are different for patients with CKD (in this woman, for example, a hemoglobin level of less than 11 g/dL would be considered anemic), the workup for anemia in patients with CKD is unique (it includes an absolute reticulocyte count), and treatment of anemia in patients with CKD usually involves institution and monitoring of erythropoietin therapy. Most important, anemia in patients with CKD that is not addressed before dialysis leads to adverse outcomes later.

Blood pressure control is important, but is not the only reason for the use of antihypertensives. Optimal care requires adjustments of ACE inhibitor therapy based on proteinuria. The rate of decline of renal function is accelerated by excess proteinuria, which is not routinely monitored by PCPs.

Left ventricular hypertrophy is an early accompaniment of CKD. Patients with CKD frequently die of cardiovascular diseases; thus, earlier diagnosis and therapy for these diseases is essential. Malnutrition is more common in patients with CKD; it can lead to hypoalbuminemia without nephrotic syndrome and accelerates loss of kidney function. If parathyroid hormone is elevated in CKD, vitamin D replacement should be initiated when levels fall below 30 ng/mL. Estrogen replacement dosages need to be adjusted in women with CKD.

These are only a small fraction of the issues covered in the CKD guidelines. PCPs do not have the time to touch all these bases; the average primary care day is already filled to overflowing.

Once the diagnosis is made, a "team approach" to care has multiple benefits, as demonstrated by a number of studies.^1,2 Using consultants and a multidisciplinary team is not a defeat. It is better for the patient and for the overworked PCP. Certain things should remain the province of the PCP, such as the oversight of blood glucose control mentioned by Dr Hirsch. However, other things are best handled by the nephrologist.

I did not mean to imply that decreased quality of care is to be blamed on overworked PCPs. Rather, it is the result of a lack of teamwork. My dad died soon after he started dialysis. In some ways, he was a casualty of inadequate CKD care-no early glomerular filtration rate (GFR) measurements, no treatment for anemia, no vitamin D replacement, and undiagnosed cardiac issues. On a personal level, I am asking how "we"-as a team-can work together constructively to find ways to comply with the lengthy CKD guidelines. The bottom line is that our answers affect patients and, sometimes, ourselves and our families.

-Gregory W. Rutecki, MD

References:

REFERENCE:

1.

Boulware LE, Troll MU, Jar BG, et al. Identification and referral of patients with progressive CKD: a national study.

Am J Kidney Dis

. 2006;48:192-204.

REFERENCES:1. Gaede P, Vedel P, Parving HH, et al. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomized study. Lancet. 1999;353:617-622.
2. Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348:383-393.