Kidney Disease

Doctor, doctor give me this news: Primary care and CKD

Many conversations have happened here regarding our Primary Care Physicians and their not telling us early enough about CKD. I found this in my current mail files and thought it was timely enough to share a physicians thoughts.

Everyone’s mind jumps right to end-stage renal disease and dialysis when kidney disease is mentioned, even among clinicians. By the time a patient needs dialysis, pathology has been smoldering, sometimes for prolonged periods of time. Nephrology gracefully manages later-stage kidney disease, but it seems the incipient cases remain in the shadows. In general practice, kidneys are often ignored.

What I want to know is this: How can we effectively forge a path between nephrology and primary care — take the reins and together harness the epidemic, starting early while the pathology of the disease may be more easily addressed?

Too many patients and too many of their primary care providers are simply unaware of renal status. The staggering number of stage 3 chronic kidney disease (CKD) cases dramatically dwindles by stage 4, and CKD exacerbates so many underlying pathologies. Morbidity leads to mortality, often without recognition of underlying kidney damage as the prominent culprit. With the worldwide nephrologist shortage, and clearly with the high cost of end-stage care, it may well be time to expand the renal education and early/moderate CKD clinical savvy in primary care.

Build CKD recognition

As a physician, I recognize pharmaceutical options as a small part of longitudinal CKD care. The point of early diagnosis is assisting patients with the arduous and necessary journey to lifestyle change. Primary care has embraced this supportive role for other diagnoses, such as cancer, diabetes, heart disease, etc. This type of synergistic/collaborative care — reinforcing specialist input, following each person with his or her myriad issues — is the perfect fit for CKD.

How do we communicate to make our generalist and specialist intent merge into one clear target — enhanced patient quality of life? How can we make this work — to commence having a serious problem-solving conversation?

The literature suggests early nephrologist involvement improves long-term outcomes. Proactive primary care offers longitudinal guidance for making the enormous lifestyle changes in diet, exercise, stress management, hydration, sleep and toxic exposures while offering psychological counseling that is required to achieve such changes. The cross-over benefits for patients’ other diagnoses is well known.

This concept of primary care nephrology could unfold into clinical reality as a professional, collaborative cooperation. With the diagnostic refinement of the nephrologist, a primary care physician can guide patients with CKD with the balancing act of comorbidities, medication management, and optimal kidney lifestyle.

Likewise, what this family physician recognizes as critically useful from the consulting nephrologist is the expert focus on pathology with a diagnosis and back-up. We must agree that things like diet, exercise, sleep, stress, and toxins have longitudinal importance for our patients with CKD — important enough for the primary care physician to make time with motivated patients to assess and co-discover actionable adaptations. Comorbidities with time will certainly guide the process. The success of this requires supportive enthusiasm from the specialist.

Vision of collaboration

Here is an example: A 46-year-old perimenopausal working single mother, with a history 12 years prior to pregnancy-induced hypertension and diabetes, has moderate proteinuria and a creatinine of 1.2. A nephrology consult will crystallize her individual needs. A primary care plan will address medications, CKD lifestyle needs and illuminate the notable overlap of benefits for her other diagnoses.

During the course of four visits looking at her stress, relationship to food and exercise needs, she exhibits admirable motivation, paying attention to what and how she eats and enjoying a lunchtime walking program. Reinforcing these successes while addressing medications, diet, sleep, etc. every 3 months offers an opportunity to protect nephrons and proceed further in the adaptations needed.

At this time, nephrologists cannot assume this is taking place in all primary care settings. Primary care providers, guiding patients with CKD safely through commonplace medical scenarios — like infectious illnesses, traumatic injuries, surgeries, travel, and stress — need to grasp a breadth of nephrology basics. Our patients with CKD are at increased risk of acute kidney injury. Astute protection means we save nephrons. This author would welcome renal rotations at all levels of medical training, with a facet of focus on longitudinal outpatient, early and moderate CKD care. This vision of collaboration, with a commitment to early diagnosis and intervention, offers the opportunity to learn how to guide patients to a less inflammatory lifestyle.

The urgency is there. Can we talk?

For more information:

Robin Rose, MD, is a semi-retired family physician with a long-time interest in chronic illness and the role of lifestyle, with an interest in incipient and moderate CKD as a current focus. She lives in Molokai, Hawaii.

12 Replies
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Thank you for great article and thoughts. I am learning too that being proactive is the solution now, and great we are able to get helpful information here. So many other medical issues are related to CKD.

Everyone is different too and reasons we get this disease are varied and also connected medical issues.

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Being proactive is important to all of us, regardless of when we were told. However, it's important for peace of mind and the understanding we get with the feeling of control over our health.

Doctors telling us sooner actually gives us the opportunity to begin to take diet and exercise steps to slow it down. So does going over medications, if any, we are already taking to avoid meds that are at cross purposes.

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Wow ........

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Yay dr rose !

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I'm very blessed to have a great primary care physician. Two years ago when I had a cold, I noticed the color of my urine looked off. Tests showed blood and protein in my urine. My PCP referred me to a Nephrologist and she said, "When it comes to your kidneys, we don't mess around. " My kidney function is normal and my creatinine is .50 (low and normal) but because blood and protein is still detected in my urine, my nephrologist has my urine and kidney function tested every three months and I see him once a year. I watch what I eat and exercise regularly. I'm really glad that I have a proactive PCP. I'm in the US and it's disheartening to know that CKD isn't taken too seriously by all medical providers.

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You are lucky to have such good PCP and Nephrologist who are pro-active.

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Great article! Yes, having the primary physician test for CkD in physicals or at least flyers in office to be made aware. Commercials, media info. Anything to get the word out for all to get checked. Simple but no-one knows to do it. Just like low vitamin D, also becoming widespread issue to be acknowledged thank you for addressing

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I totally agree, as your PCP is being paid very well to watch over and coordinate general health care; advise and refer before a problem gets out of hand and

We as the patient, must be proactive to insure that we are getting the best health care and that issues are caught early.

We have the right to see labs and have them explained to us in simple layman's terms. If there is a suspected issue, then it must be addressed and a plan set before it gets out of hand.

Knowledge is power. Knowing what steps can improve a situation and following them, puts us in a stronger position.

Great article...and true!

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Good info. My very active, intelligent and good-as-gold Nephrologist says that the education of how important kidney function is in all parts of the body, as well as information about medications (OTC and pharma) that can be harmful to kidneys, is lacking in almost all Med Schools. I had an Emory University-educated Internist overlook my Stage 4 CKD for 5+ months. She never mentioned it -- until a high potassium level from a blood test made her sit up and finally realize I was in CKD. No excuse for that!! What I tell everyone I can now? Everything you put in your mouth (period) goes thru your liver and kidneys. Do your own research and be the best advocate for your own health. P.S. I handled Medical Malpractice lawsuits against doctors and hospitals for years. I found that most people honestly believe that their doctors are educated well enough to watch out for the patient's health. Yes, well, we wouldn't have so many malpractice lawsuits if that were true!

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Excellent info!!! Yes. I know for sure that my primary waited too long. First she said stage 3, then 4 months later she said I was fine, now I suddenly am Stage 4. I am fed up with that whole network. I am changing right after my appt. with a urologist about whatever is on my kidneys.

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This is good to know i forgets that i have kidney disease until someone bring it up the Dr. said i am at 4 now but she is not doing anything she said they will just watch it. do you think they should be doing something beside that?

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In my opinion, I think you should be on a kidney-friendly meal plan, a good year-round exercise program designed by you and your Care Team, and a thorough look at all of your medications. No dyes for any Cat Scan or other types of scan. Avoid NSAIDs and only absolutely needed antibiotics except for something short-term and then only if absolutely necessary.

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