Abstract and Introduction
Abstract
Purpose of review: The majority of people with chronic kidney disease (CKD) are managed by primary care physicians and nurses, but much of the initial research on CKD care was based in secondary care. The purpose of this article is to review the important recent studies of CKD in primary care that are starting to provide an evidence base for the strategies to improve the management and outcomes of the unreferred majority of people with CKD.
Recent findings: People with CKD in primary care populations differ substantially from those familiar to nephrologists in secondary care by being older, having less reduction in glomerular filtration rate (GFR) and lower prevalence of proteinuria. These differences have important implications for management priorities. Detailed studies have identified widespread deficiencies in the care of patients with CKD in primary care (though these are also reported in secondary care). Interventions that may improve performance include automated reporting of estimated GFR, incentivizing primary care practitioners to achieve therapeutic goals and quality improvement strategies such as audit-based education.
Summary: Studies have identified a need for improved management of CKD in primary care as well as methods to achieve this. Future studies should focus on the promotion of self-management through telemedicine and the Internet.
Introduction
The publication in 2002 of the first comprehensive guidelines for the investigation and management of chronic kidney disease (CKD) by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) resulted in an intense focus of research on the many unanswered questions identified in the guidelines. Over the subsequent decade, CKD was found to be much more prevalent than previously appreciated and was identified as a major risk factor for cardiovascular disease. Important progress was also made in predicting the risks associated with CKD. Reduced glomerular filtration rate (GFR) and elevated urinary albumin excretion were identified as independent risk factors for all-cause and cardiovascular mortality as well as progression of CKD Research efforts culminated in the recent publication of a revised classification system for CKD and updated international guidelines by Kidney Disease: Improving Global Outcomes (KDIGO). It is paradoxical, however, that the majority of people newly diagnosed with CKD as a result of these initiatives led by nephrologists are not managed by nephrologists, but by community and primary care physicians and nurses. Understandably, most of the initial research on CKD was based in academic centres and tended to view CKD from a secondary care perspective. More recently, investigators have focussed on CKD management in primary care to better understand the risk profile and treatment needs of these patients. In this article, we review the important recent studies of CKD in primary care that are starting to provide an evidence base for the strategies to improve the management and outcomes of the unreferred majority of people with CKD.