Primary Care Management of Chronic Kidney Disease Stages 1-3B

Educational Objectives

The goal of this program is to improve management of chronic kidney disease (CKD). After hearing and assimilating this program, the clinician will be better able to:

1. Identify risk factors for development and progression of CKD.
2. Develop management strategies to reduce risk for complications associated with CKD.
3. Modify medication usage for patients with chronic kidney disease.
4. Refer patients with CKD to the appropriate specialists as needed.
5. Facilitate transitions of care for patients with CKD.

Summary

Role of primary care provider (PCP): primary provider of management in early stages of chronic kidney disease (CKD); PCPs are important for early recognition and delivery of care for patients diagnosed with CKD and those with end-stage CKD (post-transplantation, renal replacement therapy, conservative management); acute kidney injury (AKI) can occur in the setting of CKD; PCP may need to manage post-hospitalization follow-up for a patient admitted for AKI to ensure disease does not progress; PCP workup may be needed prior to kidney transplantation

Public health crisis: 15% of the population in the United States have CKD, and 90% do not know that they have it; 40% of adults with severe kidney disease know of their condition; 33% are at increased risk for CKD; CKD is present in ≈33% and ≈20% of adults with diabetes and hypertension, respectively; 6% and 10% of people in general and high-risk populations, respectively, are aware of their kidney disease; according to the US Renal Data System, prevalence of CKD, Medicare costs, hospitalization rates, and readmission rates are increasing; annual rates of hospitalization among people with stage 2 and stage 5 CKD are 11% and 58%, respectively

Staging of CKD: Kidney Disease Improving Global Outcomes (KDIGO) system classifies CKD based on estimated glomerular filtration rate (eGFR) and albuminuria

Assessment of CKD risk: risk for CKD increases further with multiple risk factors; social determinants of health, family history, and history of an AKI episode can increase risk for CKD; Centers for Disease Control and Prevention CKD Surveillance System calculator can assist with risk estimation

Strategies for high-risk patients: evaluate eGFR (basic or comprehensive metabolic panel) and urinary albumin to creatinine ratio (spot urine test); if normal, evaluate patient annually; if eGFR has decreased or albumin to creatinine ratio has increased, reevaluate to identify whether CKD is present; monitor frequently for patients at high risk

Evaluation: for patients with elevated albumin to creatinine ratio or low eGFR measurement, evaluate prior medical records (if available) to determine trends

Ultrasonography: recommended if no prior records are available to identify structural or obstructive cause; quality may vary based on body habitus and skill of the technician; look at kidney size, cortical thickness, echogenicity, and identify masses or calculi in renal pelvis; kidney size — average is ≈10 cm; small size and discrepancy between sides >1.5 cm suggests renal artery stenosis; large size may occur with diabetes or in early stages of CKD due to overfiltration; cysts — presence (particularly if large in size) warrants urology evaluation (small-sized cysts may be evaluated annually by PCP); cortex thickness — normal is ≈1.5 cm in healthy adults; thickness <1.0 cm suggests long-term presence of CKD

Chronicity and cause: perform comprehensive history and physical examination; conduct risk assessment; identify signs and symptoms that indicate a condition that may cause a kidney problem; urinary tract issues or systemic disease can contribute to CKD; identify use of nephrotoxic medication and social determinants of health factors (eg, environmental exposure); ensure patients have resources to sustain an appropriate diet; perform preventive screenings and immunizations to prevent risk for development and progression to end-stage CKD

Definition of CKD: may include structural or functional abnormalities (eg, congenital anomalies), presence of symptoms and signs for ≥3 mo, consistent and persistent albuminuria, urine sediment, abnormal imaging or biopsy, kidney transplant, tubular disorder resulting in electrolyte abnormalities, and eGFR <60 mL/min/1.73m²

Principles of management: include early identification, reducing risk for progression, identification of etiology, treatment of underlying conditions, management of lifestyle factors, evaluation and adjustment of medications, management of complications, and monitoring transitions of care

Lifestyle modification: includes diet, exercise, and weight management; encourage physical activity that is appropriate for the individual and avoidance of tobacco products and vaping; moderate-intensity exercise should be performed for ≥150 min/wk; encourage weight loss if appropriate

Cardiovascular disease (CVD): patients with underlying CKD are at increased risk for CVD; use risk prediction tools; consider statins, but many require dose adjustment based on renal function; monitor patients for rhabdomyolysis and elevated levels of uric acid (with CKD, colchicine is preferred and requires dose adjustment); consider lifestyle modifications and daily aspirin (if appropriate)

Hypertension: high blood pressure (BP) with CKD may be more difficult to control as CKD progresses; ensure appropriate pre-measurement approaches are taken to maximize accuracy of BP readings in clinic; 120/80 mm Hg is a general BP target but may not be tolerable for all patients (evaluate for postural hypotension); angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) — recommended for hypertension and CKD, particularly with moderate to severe increase in albuminuria; maximize dose as long as patient tolerates BP change; evaluate serum creatinine, potassium, and eGFR after initiating or changing dose of ACE inhibitor or ARB; sodium-glucose transporter 2 inhibitors — ensure patients do not develop dehydration (can lead to hypertension and AKI); monitor eGFR; discontinuation is recommended with eGFR of 20 to 45 mL/min/1.73m² (varies among different drugs in the class); mineralocorticoid receptor antagonists — may be used for people with diabetes, sufficiently high eGFR, and normal potassium levels; maximize ACE or ARB medication prior to initiating; monitor potassium according to KDIGO guidelines

Medication management: rate of inappropriate prescribing is high for patients with CKD; balance risk vs benefit of medication; people with CKD are more sensitive to nephrotoxic effects than those with normal kidney function; avoid ACE inhibitors and ARBs for people with CKD who are planning to become pregnant; provide reproductive and contraceptive counseling and monitor BP for patients taking oral contraceptives; people with CKD often have multiple providers and medications (these increase with increasing CKD stage)

Common nephrotoxic agents: include multiple medications, and herbal and dietary supplements can have nephrotoxic effects; products containing Ephedra or aristolochic acid have been linked to CKD

Referrals: may include urology, nephrology, obstetrics/gynecology, and multidisciplinary care (eg, dietitian); chronic albuminuria or hematuria warrants urgent evaluation, usually with nephrology

Stage 3b CKD: typical stage at which anemia, bone and mineral disorder (bisphosphonates need to be dose-adjusted), increased fracture risk, and electrolyte disorders appear; development of these conditions at an earlier stage warrants further evaluation

Transitions of care: people with stage 2 CKD have a median of 2 providers; people with stage 5 CKD have a median of 12 providers; communication and collaboration among providers are important for optimal care; determine patient priorities, medical needs, informed decisions, and benefits vs harms of treatment; ensure adequate communication between patient, caregivers, and health care providers

Readings

Suggested Readings

1. Clark-Cutaia MN, Jarrín OF, Thomas-Hawkins C, Hirschman KB. The perfect storm: Stakeholder perspectives on factors contributing to hospital admissions for patients undergoing maintenance hemodialysis. Nephrol Nurs J. 2020;47(1):11-20
2. Kidney Disease Improving Global Outcomes guidelines. https://kdigo.org/guidelines/. Accessed June 26, 2024
3. National Kidney Foundation. https://www.kidney.org/professionals. Accessed June 26, 2024
4. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2019 Annual Data Report: Epidemiology of kidney disease in the United States. Am J Kidney Dis. 2020;75(1 Suppl 1):A6-A7. doi:10.1053/j.ajkd.2019.09.003
5. Welch JL, Meek J, Bartlett Ellis RJ, Ambuehl R, Decker BS. Patterns of healthcare encounters experienced by patients with chronic kidney disease. J Ren Care. 2017;43(4):209-218. doi:10.1111/jorc.12200

Disclosures

For this program, Ms. Rivera and the planning committee reported nothing relevant to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.00 CE contact hours.

Lecture ID:

NP240803

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.