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A large percentage of these people have diabetes, high blood pressure the major causes of kidney damage , or both. Unless primary care providers identify these people as being at risk and start active management, these patients may silently progress to having irreversible renal failure. Therefore, it is up to primary care providers to screen and intervene long before patients feel unwell. New BC guidelines will help family doctors identify high-risk patients earlier and delay progression of kidney disease.
Additionally, it is clear that being older than 60 years combined with any of the above risk factors multiplies the risk of developing kidney disease. Some experts also believe that being of Asian, South Asian, Hispanic, or African heritage puts a patient at increased risk.
Screening in the primary care setting involves a simple blood test serum creatinine , a random urine sample for albumin-creatinine ratio ACR , and urinalysis. Abnormal results on these tests should lead to repeated testing to confirm that impaired renal function is persistent.
The importance of early and repeated screening of high-risk patients cannot be overstated. On Vancouver Island, a project called the Kidney Care Initiative has had 15 family doctors participating since in a program designed to enhance the skills of primary care providers in managing their patients with kidney disease.
Preliminary results from this project indicate a significant number of high-risk patients who were screened with simple blood and urine tests have abnormal kidney function that had not been diagnosed previously. Other studies from the US and Australia report similar findings.
Several chronic disease management projects under way in BC are now assisting primary care providers with methods of identifying these patients in their practices. Doctors with computerized records can create a registry of at-risk patients and set up reminders for repeat lab tests and office visits. Doctors in practices that are not yet automated as recommended by the Vancouver Island Kidney Care Initiative can use bright-colored stickers Figure 1 to mark charts of at-risk patients.
Each time the office staff and the physician pick up one of the stickered charts, they are reminded of the risk factors for that patient and the fact that the patient requires ongoing monitoring. For example, when a diabetic man comes in for a painful knee, everyone who sees the patient knows that his chart should have recent results from tests for glycosylated hemoglobin A1c , ACR, and estimated glomerular filtration rate eGFR , and if results are not present, these tests should be ordered.
Evaluation of abnormal test results and long-term monitoring. Enhancing the role of the primary care provider. In the past it was common for family physicians to turn over care of their patients with declining renal function to a nephrologist. This approach is no longer necessary or, from a resources point of view, even practical. Equally important is the fact that secondary prevention strategies e. Current research has proven the benefit of early intervention in the primary care setting.
The use of angiotensin-converting enzyme ACE inhibitors and angiotension receptor blockers ARBs added to other medications for hypertension and diabetes have been shown to reduce proteinuria and reduce the rate of progression of kidney disease. Smoking damages kidneys in the same way it damages the cardiovascular system. A family doctor can be a significant influence on a patient who may be thinking about quitting and needs support and motivation to do so.
Other things that family doctors can do to have a dramatic impact on the course of kidney disease include:. Note that MSP will pay for hepatitis B immunization if a patient is likely to undergo dialysis. First, the primary care provider can help the patient and family learn about kidney disease and come to accept the diagnosis.
Second, the primary care provider can work with the patient to identify goals for care, lifestyle changes, and resources for support. Third, the primary care provider can encourage the patient to monitor progress using a diary or patient flow sheet, such as the one available from BC Health Services.
These strategies encourage patients with chronic kidney disease to become actively involved in their own health care and can be successfully integrated into the primary care setting. Also, a number of chronic disease self-management courses are being offered throughout the province.
These free courses usually consist of six 2-hour sessions. They are offered in local communities so that a patient and a spouse or partner can attend together to learn about living with a chronic disease, keeping a positive attitude, and developing an action plan tailored to individual needs. Primary care providers can offer information about these courses and encourage patients to attend.
The impact of good kidney care on the individual patient as well as on the family and society as a whole is potentially enormous. By screening at-risk patients regularly, aggressively treating those with early abnormal kidney test results, and having an organized system for recall and monitoring, primary care providers can make a huge and lasting difference to their patients.
Competing interests None declare. Figure 1. Chart sticker used to identify patient at risk for kidney disease. Staging of patients with kidney disease, from BC guidelines. Guidelines and Protocols Advisory Committee. Identification, evaluation and management of patients with chronic kidney disease. BC Health Services. Coresh J, Astor BC, et al. Am J Kidney Dis ; J Am Soc Nephrol ;14 suppl 2 S Dietary protein restriction and the progression of chronic renal disease: What have all of the results of the MDRD study shown?
J Am Soc Nephrol ; Bakris GL. J Clin Hyperten ; Effect of intensive therapy on development and progression of nephropathy in the DCCT. Kidney Int ; Long-term stabilizing effect of angiotension-converting enzyme inhibition on plasma creatinine and on proteinuria in normotensive type II diabetic patients.
Ann Intern Med ; Natural course of kidney function in Type 2 diabetic patients with diabetic nephropathy. Diabet Med ; Above is the information needed to cite this article in your paper or presentation.
Solid-organ transplantation in HIV-infected patients. N Engl J Med. The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group.
Its requirements for manuscripts, including formats for bibliographic references developed by the U. An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference.
The NLM now lists all authors. Skip to main content. Issue: BCMJ, vol. Screening Screening in the primary care setting involves a simple blood test serum creatinine , a random urine sample for albumin-creatinine ratio ACR , and urinalysis. Enhancing the role of the primary care provider In the past it was common for family physicians to turn over care of their patients with declining renal function to a nephrologist.
Summary The impact of good kidney care on the individual patient as well as on the family and society as a whole is potentially enormous. Competing interests None declare Figure 1. Page numbers are not abbreviated. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
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Management of chronic kidney disease in the primary care setting
BC Guidelines are clinical practice guidelines and protocols that provide recommendations to B. Management of these conditions is beyond the scope of this guideline. However, in some cases, notes and alternatives to imaging are provided for additional clinical context. Updates in the revised version include discussion on the optimal concentration of vitamin D levels, dietary and supplemental information on vitamin D and a brief discussion on the controversies of vitamin D and chronic illness. The guideline scope includes diagnosis, investigation and management of iron deficiency in patients of all ages. It features a new algorithm for investigation of non-anemic iron deficiency in adults, a new appendix on pediatric iron doses and liquid formulations, updated medication tables, enhanced information on nutrition including vegetarian and vegan diets, and enhanced information on pediatrics.
A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.
Guidelines for the management of chronic kidney disease: Rationale, development, and implementation
Chronic kidney disease CKD is an unrecognized epidemic that has the potential to cause serious morbidity and mortality to thousands of British Columbians. It may also result in millions of dollars in new health care costs for a system already under strain. Chronic kidney disease is a prevalent problem that causes significant morbidity and mortality. Appropriate screening and early management can significantly improve outcomes. In order to assist family physicians in detecting and managing this problem, the Guidelines and Protocols Advisory Committee, a joint initiative of the BCMA and BC Ministry of Health Services, sponsored the production of guidelines for management of chronic kidney disease. These focus on the use of chronic disease management principles at the primary care level. The challenges of implementation are now being addressed by a multifaceted approach, including information dissemination, medical education, academic detailing, and the production of educational materials.