Nephrologist and Ass. Professor, Department of Internal Medicine
Family Doctor and Ass. Professor, Department of Family MedicineUniversity of Tartu, Estonia
Family Doctor and Ass. Professor, Department of Family Medicine, University of Vilnius, Lithuania
Professor of Internal Medicine, University of Tartu, Estonia
Received date: 18 March 2008 Accepted date: 24 March 2008
Chronic kidney disease (CKD) is a worldwide public health problem that is often underdiagnosed and undertreated. CKD is a ‘silent’ disease and goes un-noticed because it may not be ‘felt’. Yet it affects many more people than we might imagine: 1 out of 10 adults in the world has some form of kidney damage. However, as many as 90% of those who have CKD remain unidentified. High blood pressure and dia-betes are the main causes of CKD. It is projected that diabetes will increase by 70% by 2025. Therefore, early detection and prevention of the progression of CKD for people who also have a very high cardiovascular risk are extremely important challenges and goals for general practitioners/family doctors (GPs/FDs).
CKD represents a progressive, irreversible decline in glomerular filtration rate (GFR). Most chronic nephropathies unfortunately lack a specific treatment and progress relentlessly to end-stage renal disease (ESRD). Progressive renal function loss is a common phenomenon in renal failure, irrespective of the under-lying cause of the kidney disease. The kidney is able to adapt to damage by adaptive hyperfiltration – increas-ing the filtration in the remaining normal nephrons. As a result, a patient with mild renal insuffciency often has a normal or near-normal serum creatinine concentration. Adaptive hyperfiltration, although in-itially beneficial, appears to result in long-term dam-age to the glomeruli of the remaining nephrons, which is manifest by proteinuria and progressive renal in-suffciency. This process appears to be responsible for the development of renal failure among those in whom the original illness is either inactive or cured. The cost of the advanced renal failure and renal replacement therapy is enormous.[5,6] Therefore, early diagnosis and optimal management of CKD affords many challenges for primary health care in helping to maintain health and quality of life among the population at risk.
This position paper is based on published reviews about CKD management in different stages, and focuses on key references published since the year 2000. This position statement also provides evidence-based screen-ing recommendations and interventions for shared care between GPs/FDs and specialists.
Chronic kidney disease: definition, classification and epidemiology
The National Kidney Foundation – Kidney Disease Out-comes Quality Initiative (NKF-K/DOQI) workgroup has defined CKD as the following, which have been accepted internationally with some clarifications:[8,9]
1 the presence of markers of kidney damage for three months, as defined by structural or functional abnor-malities of the kidney with or without decreased GFR, that can lead to decreased GFR, manifest by either pathological abnormalities or other markers of kidney damage, including abnormalities in the composition of blood or urine, or abnormalities in imaging tests or:
2the presence of GFR <60 ml/min/(1.73 m2) for three months, with or without other signs of kidney damage as described above. Based upon representative samples of the US popu-lation,7 the studies have estimated the prevalence of CKD in the general population through measurement of markers of kidney damage, such as elevated serum creatinine concentration, decreased predicted GFR and presence of albuminuria.
According to the Kidney Disease: improving global outcomes (KD:IGO) position statement, the use of the term ‘disease’ in CKD is consistent with:
1 the need for action to improve outcomes through prevention, detection, evaluation and treatment
2 providing a message for public, physician and patient education programmes
3 common usage its use in other conditions defined by findings and laboratory tests, such as hypertension, diabetes and hyperlipidaemia.
strong>Classification of CKD
CKD is classified according to severity, diagnosis, treatment and prognosis.9 Five-stage classification is based on structural and functional criteria regardless of the cause and accounting for dialysis and trans-plantation (see Table 1). The suffx ‘T’ is used for all transplant recipients, at any level of GFR, and ‘D’ for dialysis, for CKD stage 5 patients treated with dialysis.
Epidemiology of CKD
Clinical evaluation for CKD should include eluci-dation of the cause of disease. However, the cause of the disease cannot be ascertained in all cases. Also, renal function declines normally with age, and the exact level of decline at a given age that should be considered pathological is not known. The KD:IGO statement considers GFR less than 60 ml/min to be pathological at all ages. Cross-sectional studies re-port a slow decline in GFR after the fourth decade of life of _0.75 ml/min/(1.73 m2)/year. These changes proceed slowly but in the presence of other diseases such as diabetes, hypertension and heart disease, the kidney becomes vulnerable to failure.
Very few of the causes of chronic renal failure are completely curable. It is often not necessary to do extensive tests to find a cause, especially when symptoms of renal insuffciency are already present. However, for determining the stage and specific characteristics of the underlying disease, follow-up of patients and thorough diagnostic work-up is needed. Diabetes is one of the commonest causes of kidney failure after glomerulo-nephritis in many countries.[12-15] The major groups ofdiseases leadingto ESRD are glomerulonephritis, diabetic nephropathy, hypertension, chronic pyelonephritis and polycystic kidney disease. In different countries the proportions of these diseases as a cause of renal failure vary: e.g. glomerulonephritis accounts for 22– 24% of renal replacement therapy (RRT) patients in Estonia, Germany, Poland or Finland, but only 11– 12% in France, Italy or England. Patients of diabetic nephropathy form 12% of RRT patients in Italy, 22% in Estonia, 24% in Finland and Poland, 23% in Germany, 12% in England, 30% in Japan, and 37% in the US.[16-19]
The use of RRT varies in different countries. There is a rising incidence and prevalence of kidney fail-ure,[12–15] and the worldwide epidemic of CKD shows no signs of abating in the near future. The exact reasons for the growth of ESRD are unknown. Changes in the demographics of the population, differences in disease burden among different racial groups and under-recognition of earlier stages and of risk factors for CKD may partially explain this growth. Recent trends show that the rate of increase of new cases of both diabetic and all-cause ESRD has progressively levelled off in many countries.[13,20] It is therefore currently impossible to predict the long-term trend of RRT in Europe. The prevalence of RRT patients/ million inhabitants in 2005 was very different world-wide: in Estonia it was 394, in Finland 722, in Sweden 818, in Germany 1057, in Spain 899, in England 668 and in the US 1590.[16,17]
It has been shown that CKD affects men more often than women. For example, according to the Finnish Registry for Kidney Diseases, the prevalence of RRT in men was 898 and in women 553/million inhabitants in 2006. Since 1996, the prevalence of RRT has increased faster among men (63%) than among women (44%). The prevalence among the elderly is growing rapidly: in the age group 75+ years, the prevalence of RRT has increased by almost 250% during the past ten years and 70% during the past five years. In the younger age groups, the prevalence has increased 10–61% in ten years and 4–14% in five years.
Management of chronic kidney disease patients
Risk groups and screening
Detection of CKD is believed to be a priority for primary care because early treatment of CKD and its complications may delay or prevent the development of ESRD. It would be ideal for GPs/FDs to carry out screening, as the majority of the population visits their GP/FD within a 3-year period and can be subject to screening. There are reports suggesting that CKD is often not detected, even when patients have access to primary care. There is an overwhelming consensus that screening for CKD should include high-risk groups. Screening for asymptomatic persons beyond the above-mentioned patient groups has not yet found justification. Early detection of diabetes and hyper-tension as the most important reasons for CKD, and their appropriate treatment is a method of avoiding or postponing complications, including chronic kidney failure. Screening of hypertension by measurement of blood pressure at GP/FD surgery visits has found support in many guidelines. However, systematic diabetes screening of members of the general popu-lation without symptoms or risk factors has not been found to be effective.
Risk groups for chronic kidney disease are those with the following:
•a family history of diabetes or hypertension
•recurrent urinary tract infections
•systemic diseases that affect kidneys
•past or family history of cardiovascular disease.
The most widely used methods for screening for kidney disease are:
1 an analysis of a random urine sample for albumi-nuria
2 a serum creatinine measurement to calculate an estimated GFR, which is an indication of func-tioning kidney mass.
It is recommended to use both of these methods, as significant kidney disease can present with diminished GFR or proteinuria, or both. Detecting and quan-tifying proteinuria is essential to the diagnosis and treatment of CKD. Albumin, the predominant protein excreted by the kidney in most types of renal diseases, can be detected by urine dipstick testing. The protein– creatinine ratio in an early-morning random urine sample correlates well with 24-hour urine protein excretion, and is much easier to obtain. Albuminuria often heralds the onset of diabetic nephropathy; thus this sample is therefore recommended for all patients atriskforkidneydisease. The quantitative determination of protein in the urine in the lab is more economical and more correct than the use of microalbuminuria dipsticks, and should be the recommended method to detect proteinuria. The term ‘albuminuria’ should be substituted for the terms ‘microalbuminuria’ and ‘macroalbuminuria.’ These terms are commonly used but should be avoided because they are misleading. Increased urinary excretion of albumin is the earliest manifestation of CKD due to diabetes, other glom-erular diseases and hypertensive nephrosclerosis. Also, albuminuria may accompany tubulointerstitial dis-eases, polycystic kidney disease and kidney disease in transplant recipients.
Significant kidney dysfunction may be present despite a normal serum creatinine level. An estimated GFR based on serum creatinine level correlates better with direct measures of the GFR, and detects more cases of CKD than does the serum creatinine level alone. Clinically useful GFR estimates are calculated from the measured serum creatinine level after adjust-ments for age, sex and race.[24,25] The two most com-monly used formulae for GFR estimation are theMDRD (Modification of Diet in Renal Disease) study equation and the Cockcroft–Gault equation (see Table 2). Validation studies in middle-aged patients with CKD showed the MDRD study equation to be more accurate. However, the MDRD study equation was found to systematically underestimate the GFR in patients without CKD. It is important to realise that the methodology used for determination of serum creatinine is of great importance in the interpretation of the results obtained with the MDRD formula, and that in fact only the IDMS-corrected serum creatinine can be used. It should be kept in mind that these formulae do not result in correct GFRs when used in persons with abnormal body composition: the obese, patients with oedema, pregnant women, those in states of cachexia, or amputees. In most situations of FDs, and as long as kidney function is stable, a calculated GFR can replace measurement of a 24-hour urine collection for creatinine clearance, but this is still required in pregnant women, patients with extremes of age and weight, patients with malnutrition, patients with musculoskeletal diseases, paraplegia or quadri-plegia and patients with a vegetarian diet or rapidly changing kidney function. Also, creatinine clearance is preferred in pre-dialysis and transplant patients.
Screening of risk populations may help early detection of kidney disease by GPs/FDs and enable the use of primary prevention strategies to avoid the develop-ment of diabetic or hypertensive nephropathy that may occur over many years and decades.
Primary prevention interventions seek to delay or halt the development of CKD. This involves public health measures to influence smoking cessation, mod-ification of wrong dietary habits, and reduction of the prevalence of obesity among the population. Secondary and tertiary prevention interventions include preven-tion strategies for individuals with CKD, and seeking to prevent (secondary) or control (tertiary) compli-cations of renal insuffciency Primary and secondary prevention of cardiovascu-lar disease (CVD) and CKD remain the main purpose in modern medicine, as the main cause of death in patients with CKD is cardiovascular disease. The risk of death in CKD stage 4–5 patients is 10–20-fold that of the general population.[28,29] CKD patients belong in the highest-risk group for subsequent atherosclerotic complications. Therefore, CKD should be recognised as early as possible, and all prevention interventions that may arrest the progression of kidney disease and cardiovascular disease should be used.
When kidney disease progresses, CKD patients become hypertensive, and develop combined hyper-lipidaemia and hyperhomocysteinaemia, increased oxidative stress and decreased physical activity and psychosocial stress. If patients choose to smoke, the additive risk is profound. Diabetes mellitus is a major risk factor for both CVD and CKD progres-sion. Moreover, CKD patients are usually older and are often menopausal if female. Finally, CKD patients have a dramatic tendency for vascular and cardiac calcification that is related to hyperphosphataemia and secondary hyperparathyroidism. Therefore, modifi-cation of cardiovascular risk factors, both classical and those associated with renalinsuffciency(uraemic toxins, hyperphosphatemia, prolonged oxidative stress, mal-nutrition, hyperuricemia etc) should be considered in the management of CKD patients.
Secondary prevention and management of several renal and CVD risk factors such as hypertension, being overweight, hypercholesterolaemia, hypertriglyceri-daemia and others should begin early in the course of CKD, with renoprotective and vasoprotective med-ications. Hypertensive diabetics and those with micro-albuminuria or macroalbuminuria, whether hypertensive or not, should be treated with renin–angiotensin system (RAS) blockers of either an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB). ACE inhibitor therapy also lowers the rate of progressive kidney disease in children and young adults with immunoglobulin A (IgA) nephro-pathy and moderate proteinuria. In addition to classical risk factors, patients with CKD have specific risk factors (see Table 3). Psychosocial factors, such as environmental stress and responsiveness to stress, should not go unmentioned, especially when the patient is referred late to a kidney clinic.
Principles of management of CKD: role of the GP/FD and shared care
As the population with chronic renal failure grows, primary care physicians will increasingly be involved in the management of these patients. GPs/FDs have an important role in detecting CKD early, in taking measures to slow the disease progression and in providing timely referral to a nephrologist. How-ever, who is responsible for CKD patients, whether the GP/FD or the specialist, depends on the stage of CKD and often on the organisation of the healthcare system. Several models of care of CKD patients are possible: a primary care-based model (conventional shared care between GPs and hospital-based nephrologists), sec-ondary care-based model, or a model of specialised kidney centres besides routine primary and secondary care. International evidence indicates that health sys-tems based on well-structured and organised primary care with adequately trained GPs provide both more cost-effective and more clinically effective care than those with a low primary care orientation. However, there is no specific evidence for the cost-effectiveness and clinical effectiveness of primary care in the specific case of CKD. There are few data about management of CKD in primary care, and the data vary a lot from excellent to poor quality of care.[40-43] In addition, high total quality of care was achieved in most of the studies on CKD management in nephrological centres.[44,45] The few studies that directly compared primary and nephrological care in advanced CKD supported man-agement of CKD in nephrological centres.[42,46] In the guidelines of the UK, Canada and Australia, co-man-agement of patients referred to a nephrologist with their primary care physician and other healthcare pro-viders, to enable a shared care model is suggested, which defines the roles and the ways of communi-cation, but their implementation may be problematic.
The most important role of GPs/FDs in the man-agement of CKD patients is detecting and treating possible reversible causes of renal dysfunction, and preventing the progression of CKD and CVD. It is important to consider the patient‘s renal function in prescribing and, nowadays more importantly, in plan-ning radiological investigations with contrast media. However, when symptoms of renal insuffciency be-come more pronounced, referral to and shared care with a nephrologist is essential (see Table 3).
The gradual decline in function in patients with CKD is initially asymptomatic. Different signs and symptoms may be observed with advanced renal dys-function, including volume overload, hyperkalaemia, metabolic acidosis, hypertension, anaemia and bone disease. A shared care, including involvement of a nephrologist, primary care physician, renal dietician, nurse and social worker, should be initiated early in the course of CKD, with close patient follow-up.
Management should include measurements of serum creatinine concentration and estimated GFR, haemoglobin, calcium, phosphate, potassium, bicar-bonate and parathyroid hormone (PTH) concentra-tions, dietary assessment, treatment of anaemia with intravenous iron _ erythropoiesis-stimulating agents, treatment of hyperparathyroidism and phosphate reten-tion, correction of acidosis, counselling and education about the options for RRT and conservative (non-dialytic) management. Conservative (palliative) treat-ment may still include drug treatment of hypertension, anaemia, phosphate retention, hyperparathyroidism and acidosis if the patient chooses not to undergo RRT.
Early referral to a nephrologist
Patients with CKD stage 1 and 2 should be treated in primary care, while the nephrologist’s task is seen to be providing RRT. Late referral to specialist care for renal failure is associated with increased morbidity, mor-tality and cost. The criteria for referral to a nephrologist are shown in Box 1.[48,49]
Pre-dialysis and renal replacement therapy: role of primary care and nephrologists
The availability of RRT forces the nephrologist to consider its application in every patient in whom it might be indicated. As kidney disease progresses, patients cannot get help only from GPs/FDs because of pre-dialysis activities and preparations for RRT, which take several months. Patients often feel that the nephrologist is the only doctor who should manage all medical problems.
There are many clinical problems in patients with CKD during the pre-dialysis and RRT period; these can be associated with CKD, but not always. There-fore, nephrologists often provide primary care or non-renal-related medical care to pre-dialysis patients or to patients undergoing chronic haemodialysis, because these patients visit the centre often. Patients also often feel that the nephrologist should manage even their acute illness, because the nephrologist is the first person who makes the diagnosis of acute illness. On the other hand, comparison of haemodialysis and peritoneal dialysis (HD, PD) patients showed that PD patients depended upon their nephrologists less.
A paucity of objective data exist concerning the nephrologist’s role as a primary care provider: the volume and type of practice provided by the nephrol-ogist for patients with ESRD may be similar to that of the GP/FD.[51–54] During the pre-dialysis period and especially during RRT, patients visit the kidney centre more often than the GP/FD surgery. Therefore, as well as the RRT, nephrologists also have to deal with other general health problems (infections, traumas, drug prescription, social problems etc), which may or may not be associated with the CKD. Examples are a pre-dialysis diabetic patient with CKD and leg ischaemia, a peritoneal dialysis patient with abdominal pain, a transplanted patient with fever, or a haemodialysis patient with oedema.
The results of a recent study that estimates the annual cost of implementation of the guidelines on newly identified CKD cases among family doctors show significant increases in nephrology referral and additional investigation. The projected cost per prac-tice of investigating stable stage 3 CKD patients was lower than for nephrology referral. More studies should be performed to compare long-term life qual-ity and economic aspects in different managed care practices. Itis possible that although in the first year CKD patient management costs are higher in specialised care settings, the long-term costs may be lower because of the better care.
Some nephrologists feel that the GP/FD should be the first to encourage the use of home-based dialysis therapies such as peritoneal dialysis. In practice, how-ever, most GPs/FDs seem to be afraid of such methods. Once a patient is already undergoing dialysis therapy, the role of the GP/FD differs from country to country. In the UK, haemodialysis patients are seen by their nephrologist only once every month, so here the GP/ FD might have an important role. In other countries, for example Belgium, haemodialysis patients are seen three times a week by their nephrologist.
Social support is an understudied, yet important, modifiable risk factor in a number of chronic illnesses, including CKD and ESRD. Increased social support has the potential to positively affect outcomes through a number of mechanisms, including decreased levels of depressive effect, increased patient perception of quality of life, increased access to health care, increased patient compliance with prescribed therapies, and direct physiological effects on the immune system. Higher levels of social support have been linked to survival in several studies of patients with and without renal disease. CKD patient education during the pre-dialysis period also involves management of future social needs. In patients who are students or still working, a suitable RRT method will usually be considered.
CKD occurs in patients with complex medical and social problems. CKD management requires that multidisciplinary professionals provide patient edu-cation, disease management and psychosocial sup-port. To remain cost-effcient, many physicians are training and supervising mid-level practitioners in the delivery of specialised health care. In the US and other countries, CKD clinics have been organised to better meet the specific needs of CKD patients. Multi-disciplinary collaboration among physicians (GP/FD, nephrologist, cardiologist, endocrinologist, vascular surgeon and transplant physician) and participating caregivers (nurse, pharmacist, social worker and diet-ician) is also critical. There are several potential barriers to the successful implementation of a CKD/ESRD programme, including lack of awareness of the disease state among patients and healthcare providers, late identification and referral to a nephrologist, and com-plex fragmented care delivered by multiple providers in many different sites of care. Whether the multi-disciplinary team is built around specialist services or primary care will depend on the particular healthcare system. However, primary care is an environment that permits better co-ordination of medical and social care.
Different infections are associated with CKD. The occurrence of urinary tract infection (UTI) is frequent and may complicate the course of CKD. Despite the frequency of renal impairment as a result of diabetes, the management of UTI in patients with CKD or renal failure has not been a focus of published literature. Hepatitis- and human immunodeficiency virus (HIV)-infected patients can develop different types of CKD. At the time of HIV diagnosis, all patients should be assessed for existing kidney disease with a screening urine analysis for proteinuria and a calculated estimate of renal function.[20,59,60] Infectious diseases are the second most common cause of death in ESRD patients. Hepatitis C is a complicating factor among patients with ESRD. The source of hepatitis C virus (HCV) infection in these patients can be nosocomial. Screening and careful attention to infection control precautions are mandatory for dialysis units to prevent the spread of HCV.
Regardless of age and the presence of other co-morbid illnesses, it is recommended that patients with CKD receive regular vaccinations. Responsiveness to vaccination in patients with CKD can be diminished, but adequate seroresponse with standard or augmented regimens for vaccinations against influenza, hepatitis B, pneumococcus and other infections have been documented (see Table 4). Live vaccines (yellow fever, polio, varicella and measles, mumps and rubella (MMR) vaccines) are generally avoided because they present a theoretical risk of vaccine-induced infec-tion.
Dietary recommendations are important in the man-agement of CKD and the maintenance of broader health in CKD patients. In early stages of CKD, dietary protein restriction is the first recommendation for preventing its progression.[64,65] However, the effects of dietary protein restriction in humans are controver-sial.[66–69] Guidelines suggest that the protein content of the diet should not be lower than 0.75 g/kg/day and should not exceed 0.8–1.0 g/kg/day.70 The desire to maintain adequate nutrition among patients with chronic renal failure clearly competes with attempts to slow the progression of renal dysfunction with the use of a low-protein diet, since this level of restriction avoids protein malnutrition and may slow progressive disease. All patients with stage 4–5 CKD should undergo regular nutritional screening by a dietician. Nutritional assessment should include a minimum of a record of body weight prior to the onset of sickness, current body weight and ideal body weight; body mass index (weight/height2); and subjective global assess-ment. Other measures of nutritional state are: serum creatinine, serum lipids, serum albumin and handgrip strength.[65,71] The dietary recommendations are dif-ferent in all countries, but all guidelines agree that the energy intake in CKD patients of 30–35 kcal/kg/day may be suffcient. Sodium, total fat, cholesterol, carbo-hydrate, protein, phosphorus and potassium are re-stricted for all CKD patients.
Anaemia is an early and common complication of CKD. The GP’s/FD’s role should involve measure-ment of haemoglobin (Hb) concentration, mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH) to assess the type of anaemia, absolute reticulocyte count to assess erythropoietic activity, plasma/serum ferritin concentration to assess iron stores, plasma/serum C-reactive protein (CRP) to assess inflammation, and assessment of occult gastrointestinal blood loss. GPs can usually treat most causes of anaemia. Patients with a GFR <60 ml/min/ (1.73 m2) should have their Hb level checked, and if it is found to be low then their anaemia should be further investigated and treated, usually by a neph-rologist. The recommended Hb levels at which ther-apy with an erythropoietic agent should be initiated is <110 g/l.
Education and quality of care
Education about the CKD, risk factors of the CKD progression and treatment with RRT should be viewed at different levels: medical professionals (nephrologists, internists, primary care doctors, nurses), patients, rela-tives and public health professionals. A modern approach to CKD and the concept that CKD is a risk factor for cardiovascular disease and needs to be managed (as does diabetes and dyslipidaemia) should be included in the undergraduate and postgraduate curriculum of physicians everywhere. The free movement of doctors throughout the European Community has lead to har-monisation of medical education to ensure common standards of care.
Awareness of CKD risk factors among GPs/FDs who treat high-risk populations, such as persons with dia-betes, persons with hypertension and family members of dialysis patients, should be excellent. Only GPs/FDs can diagnose the disease early and give advice to patients about the management of the risk factors that may lead to CKD progression. Primary care physicians and nurses need targeted education to increase awareness of populations at high risk for CKD.
Timely education of CKD patients, their family members and close friends and/or primary care pro-viders is critical for both HD and PD. Studies have shown that this can both improve outcomes and reduce costs. Nephrology nurses are often crucial for educating patients with CKD, patients with ESRD, family members and caregivers.
Hypertension and diabetes care guidelines have recently been updated. Many guidelines have also been worked out exceptionally for nephrologists. A nephrologist’s conformity to guidelines has been shown to be systematically better than that of non-nephrologists. Published analyses reveal that a large number of patients with advanced CKD are being treated solely by non-nephrologists, and that nephrol-ogists treat patients with more-advanced disease.
In order to improve patient outcomes, there is a need to take a more holistic approach to the problem, by co-ordinating the efforts of policymakers, those involved in healthcare system redesign, clinicians and researchers. In doing so, there should be an improve-ment in both identification and management of patients with impaired kidney function, whether cared for by primary care physicians, specialists, or nephrologists, and irrespective of the healthcare system.
Quality of care in CKD
Monitoring quality, particularly when clinically detailed measures are combined with appropriate incentives, may be one of the most effective ways to improve performance on targeted measures. However, quality monitoring is only one aspect of quality management. Training of health staff, promoting the use of guide-lines, having a database of chronically ill patients, call/ recall systems, early recognition and referral, improved information systems, etc, are other very important tools in improving the quality of care of chronic patients. Wagner worked out the widely accepted model of improvement of chronic disease manage-ment, which includes several components that are also important when talking about CKD management.
Training of health staff
Several studies have shown that there is a lack of awareness of evidence-based guidelines for CKD, a large variability in the treatment of complications of CKD, and uncertainty of timing for referral to a nephrologist. The need for targeted training to raise the awareness of clinical practice guidelines and rec-ommendations for patients with CKD among primary care physicians is emphasised.[42,82,83]
Existence and implementation of evidence-based guidelines for management of CKD patients
For optimal management of patients with CKD in primary care, good guidelines are needed, including identification of those who would benefit from referral to specialist services. Formulating and implementing specific treatment strategies are key factors in the success of achieving quality patient outcomes. Evi-dence-based guidelines for management of CKD have been developed in several countries.[47,48,84] As a varietyof models have been proposed and implemented to improve CKD care, careful evaluation of what works and what does not work in the current clinical envir-onment is needed. Guidelines need to be adapted to local situations in order to be acceptable and imple-mented.
Information system facilitating the development of disease registries, tracking systems and reminders
Early identification of CKD is important as it allows appropriate measures to be taken to slow or prevent the progression to more serious CKD and also to combat the major risk of illness or death due to cardiovascular disease. Studies of general practice computerised medical records show that it is feasible to identify people with CKD, and that computer records are a valid source of data. The UK Quality and Outcomes Framework has a very good example in having a valuable database of chronic patients and improving the quality of care. This system also con-sists of indicators for monitoring CKD, e.g. the per-centage of patients on the CKD register in whom the last blood pressure reading, recorded in the previous 15 months, is 140/85 mmHg or less; the percentage of patients in the CKD register with hypertension who are treated with an ACE inhibitor or ARB.
Reorganising team function and practice systems to meet the needs of CKD patients and ensuring access to services that are proven to improve outcomes
Recognition of CKD by the treating physician, and timely nephrology referral are shown to be essentialcomponents for providing adequate care to patients with CKD.[27,84] Several authors believe that patients with CKD require a multidisciplinary team approach that focuses on early diagnosis of CKD, identifying and managing the complications of CKD, co-morbid conditions and smoothing transition to RRT. There should be integrated services with primary care, specialist services (nephrologist, endocrinologist, cardiologist,surgeon), nurses, a dietician and a palliative careteam.[47,57,87,88]
1 Health systems should guarantee the access of the population to primary care, with referral to sec-ondary care, if needed.
2 Primary care should have a leading position in implementing the screening programmes for CKD in risk groups, and health systems should provide
resources for this.
3 Primary care is in an ideal position to implement primary and secondary prevention of CKD. It is important to realise that CKD adds significantly to the overall cardiovascular risk; therefore, its pre-
4 Optimal co-operation between primary and sec-ondary care should be developed for CKD patients. Shared-care models permit better co-ordination of services and are more cost-effective.
5 In primary health care, teams of GPs and other specialists should be involved. It is important to collect evidence of the role of primary care in prevention and care for patients with CKD. For advanced CKD cases when renal replacement ther-apies are used, nephrology teams have a major role. Even in this phase, good co-operation between primary and secondary care permits the best re-sults for patients and for society. Educational pro-grammes for different levels of patients, nurses and doctors are of utmost importance for achieving the best outcomes.
The authors thank Peter Groenewegen, Wim Van Biesen, Heidi-Ingrid Maaroos, Kaja Po˜lluste, Aivars Petersons and Arnoldas Jurgutis for valuable com-ments and suggestions in discussing the paper.
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