Help patients with chronic kidney disease stave off dialysis

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Applied Evidence

Help patients with chronic kidney disease stave off dialysis

J Fam Pract. 2010 April;59(4):212-219

By

Ariel Linden, DrPH, MS

Thomas J. Biuso, MD, MBA

Susan W. Butterworth, PhD, MS

Screening and timely referral are, of course, key. But this health coaching technique can make a big difference, too.

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References

1. US Renal Data Systems. USRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease & End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2009.

2. National Kidney Foundation. KDOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. 2002. Available at: http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm. Accessed January 12, 2009.

3. U.S. Department of Health and Human Services. Healthy People 2010. (“Understanding and Improving Health” and “Objectives for Improving Health,” 2 volumes.) 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.

4. Fox CH, Brooks A, Zayas LE, et al. Primary care physicians’ knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study. J Am Board Fam Med. 2006;19:54-61.

5. Lea JP, McClellan WM, Melcher C, et al. CKD risk factors reported by primary care physicians: do guidelines make a difference? Am J Kidney Dis. 2006;47:72-77.

6. Foley RN, Murray AM, Li S, et al. Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999. J Am Soc Nephrol. 2005;16:489-495.

7. Nissenson AR, Collins AJ, Hurley J, et al. Opportunities for improving the care of patients with chronic renal insufficiency: current practice patterns. J Am Soc Nephrol. 2001;12:1713-1720.

8. McClellan WM, Knight DF, Karp H, et al. Early detection and treatment of renal disease in hospitalized diabetic and hypertensive patients: important differences between practice and published guidelines. Am J Kidney Dis. 1997;29:368-375.

9. Obrador GT, Ruthazer R, Arora P, et al. Prevalence of and factors associated with suboptimal care before initiation of dialysis in the United States. J Am Soc Nephrol. 1999;10:1793-1800.

10. Boulware LE, Troll MU, Jaar BG, et al. Identification and referral of patients with progressive CKD: a national study. Am J Kidney Dis. 2006;48:192-204.

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12. Wauters JP, Lameire N, Davison A, et al. Why patients with progressing kidney disease are referred late to the nephrologists: on causes and proposals for improvement. Nephrol Dial Transplant. 2005;20:490-496.

13. Ouseph R, Hendricks P, Hollon JA, et al. Under-recognition of chronic kidney disease in elderly outpatients. Clin Nephrol. 2007;68:373-378.

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PRACTICE RECOMMENDATIONS

• Screen all patients for chronic kidney disease (CKD) by estimated glomerular filtration rate and persistent proteinuria. A

• Treat all CKD patients with angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors, unless there is a contraindication. A

• Recommend a heart-healthy diet and refer patients with CKD to a registered dietitian for more intensive dietary modifications. A

• Integrate motivational interviewing into your care of CKD patients. This health coaching technique has been shown to be causally and independently associated with positive behavioral outcomes. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Over the last decade, the prevalence of chronic kidney disease (CKD) has grown approximately 20% to 25%, and current estimates are that the disease affects about 15% of the general population.¹ All-cause hospitalization rates are almost 3 times higher among CKD patients than in those without the disease, and costs associated with CKD account for as much as 28% of the Medicare budget.¹ Most disturbingly, the incidence at which patients diagnosed with CKD progress to end-stage renal disease (ESRD) continues to increase annually, reaching 354 cases per million population in 2007.¹ By 2020, estimates are that more than 750,000 people in the United States will need dialysis for kidney failure.¹

Guidelines exist, but awareness falls short
Several initiatives to increase awareness of CKD have been publicized. They include the Kidney Disease Outcome Quality Initiative (KDOQI) of the National Kidney Foundation (NKF), which issued clinical practice guidelines for treating chronic kidney disease in 2002, and Healthy People 2010, which includes specific measures to reduce the number of new cases and the complications, disability, economic costs, and mortality associated with the disease.^2,3 Despite these efforts, studies show that many primary care providers are still unaware of these guidelines.^4,5

Patients go undiagnosed until they reach the later stages of the disease, and many receive suboptimal care—even when they are identified—including lack of timely referral to a nephrologist and inadequate management of CKD comorbidities.^6-13 (More on comorbidities, in a bit.)

Plus, there’s a lack of support … Care for these conditions is complex and difficult, and consultation or referral to a nephrologist may not be readily available, as the current pool of specialists is barely adequate to meet the needs of a growing population of CKD patients and the number of physicians-in-training entering the specialty is not adequate to meet the need.¹⁴ In this situation, primary care providers will have to assume an ever-enlarging share of the responsibility for care of CKD patients, including some clinical activities that are currently performed by specialists.

The first step: Screen all patients for CKD

Incorporating CKD screening into routine blood work for all patients facilitates earlier detection, evaluation, and treatment of the disease. Screening tests include the estimated glomerular filtration rate (GFR) based on serum creatinine as well as measurements of urine albumin and proteinuria. The persistence of proteinuria must be confirmed by 2 of 3 abnormal readings over a minimum of 3 months, because factors such as fever or exercise may affect test results. Measurement of albumin or total protein concentration in a spot sample avoids the need for timed collections. Factoring the concentration of total protein or albumin by urine creatinine concentration and using age/sex-specific thresholds eliminates most variations in measurement.¹⁵

Keep these comorbidities on your radar screen

FAST TRACK

Decreased glomerular filtration rate is an independent risk factor for cardiovascular disease outcomes and all-cause mortality.

Diabetes and hypertension are 2 of the most common causes of CKD in the United States, and the number of kidney failure cases due to these problems is increasing. The most important adverse outcomes of CKD are not only progression to ESRD, but also increased risk for cardiovascular disease (CVD). Studies show that the presence of albuminuria and a decreased estimated GFR consistently and incrementally increase the risk for CVD.¹⁶ Decreased GFR is an independent risk factor for CVD outcomes and for all-cause mortality, including sudden death in patients with existing coronary artery disease. Moreover, patients with CKD are 100 times more likely to die from CVD than to develop kidney failure.¹⁶

Depression is another prevalent, yet commonly overlooked, comorbid condition. Patients with any chronic disease are at risk for depression, with the incidence rising with the severity of the medical condition.¹⁷ CKD is no exception. Rates of depression as high as 29%, as well as rates of anxiety disorders as high as 46%, have been documented in patients on dialysis.¹⁸ Patients with depression are impaired in overall functioning and less able to follow medical regimens.¹⁷ In addition, low quality of life and depression predict higher morbidity and mortality rates in patients with ESRD.¹⁹ Because the diagnosis of depression is frequently missed in primary care settings, screening for depression should be a basic element in CKD management.²⁰