Chronic Kidney Disease in Primary Care: An Opportunity for Generalists

Excerpt

Chronic kidney disease (CKD) is a public health concern affecting nearly 26 million Americans.1 However, unlike other chronic conditions with a similarly large prevalence in the US (e.g., hypertension, diabetes mellitus, and chronic obstructive pulmonary disease) and despite the association between CKD and morbidity and mortality, CKD has been largely under-recognized and not aggressively treated by primary care providers (PCP).2,3 In a landmark paper in 2004, Go et al. demonstrated a strong graded association between worsening kidney function and risk of hospitalizations, cardiovascular events, and death.4 More recent studies have corroborated these findings5 and also linked CKD to increased rates of disability,6,7 poorer quality of life,6 greater cognitive decline,8 and an increased number of infections.9 Importantly, there is now strong evidence that medical therapies can alter the course of disease.10 Providers can slow progression of CKD to end-stage renal disease (ESRD) with good blood pressure control (particularly among those with macroalbuminuria),11 tighter glycemic control,12 decreased albuminuria through the use of angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB),13 and by limiting the use of nephrotoxic medications such as non-steroidal anti-inflammatory agents.14 Emerging therapies such as daily administration of oral sodium bicarbonate also show promise.15 Less strong evidence suggests that providers can also modify the high morality rate associated with CKD via similar mechanisms, including blood pressure control and use of ACEI/ARBs and HMG Co-A reductase inhibitors for cardiovascular risk reduction.13,16 …