Chronic kidney disease in primary care

Because chronic kidney disease is a growing health concern, family physicians must be equipped to care for this unique patient population. Diabetes mellitus and hypertension, which are commonly addressed in the office setting, are the largest contributors to chronic kidney disease; therefore, these risk factors should be tightly controlled and these patients should be screened closely for signs of renal damage. The National Kidney Foundation recommends that screening include determination of the glomerular filtration rate (GFR) and assessment for the presence of proteinuria. Once the diagnosis of chronic kidney disease is established (by the presence of persistent kidney damage or a GFR <60 mL/min/1.73m(2) for at least 3 months), the etiology of chronic kidney disease needs to be elucidated. Often the etiology can be determined by history alone; however, reversible causes of chronic kidney disease should be considered in all patients. Regardless of the underlying etiology of the chronic kidney disease, the family physician can make a significant impact in slowing the progression of chronic kidney disease through strict blood pressure control, tight glycemic control, reduction in the degree of proteinuria, and smoking cessation. All chronic kidney disease patients are at significantly increased risk of cardiovascular events; therefore, additional cardiovascular risk factors such as hyperlipidemia should be managed aggressively. Assessment for the complications of chronic kidney disease, including anemia, bone metabolism abnormalities, metabolic acidosis, and malnourishment, should be assessed once the GFR declines below 60 mL/min/1.73m(2) (stage 3). Early screening and treatment of these complications can prevent the development of further sequelae and should not be delayed until referral to nephrology. Appropriate counseling and health maintenance is also needed for this patient population and should be given by the family physician involved in the patient's care.