What every patient needs to know about chronic kidney disease:

Your doctors might have told you that you have chronic kidney disease, a very common condition in clinical medicine. Chronic kidney disease (CKD) is especially common in patients with diabetes and hypertension. Recent evidence suggests that by the time proteinuria is present, the disease has already advanced. The presence of small amounts of protein in the urine suggests not only that kidney disease is present, but that you are at risk for cardiovascular disease, as well. The presence of an elevated urine albumin creatinine ratio signifies that there may be early damage to the cells lining the blood vessel walls.

You are hardly alone; there are an estimated 19 million patients with chronic kidney disease, though only roughly 300,000 reach dialysis. Many patients who have CKD also have underlying cardiovascular disease with hypertension and diabetes. Thus, it is more likely that a kidney patient will suffer a stroke or cardiac event than reach dialysis. Patients who are diagnosed with kidney disease must take every opportunity to reduce the risks factors that will lead not only to renal failure, but also to cardiovascular events. In reviewing the data from a major health plan, it was noted that circulatory causes accounted for the majority of hospital charges in the six months prior to the initiation of dialysis. (Personal communication) Congestive heart failure is almost always associated with decreased renal function.

Management principles

1. There are five stages of kidney disease. These are determined by successive measurements of the MDRD GFR over a three month period. The GFR (glomerular filtration rate) is a test used by doctors to determine how well the kidney functionTable 1 highlights these stages and Table 2 defines CKD. The MDRD GFR is based upon an analysis of patients who were part of the large Modification of Diet in Renal Disease (MDRD) Clincal Trial published in 1993. To analyze these patients and determine whether protein restriction delayed disease progression, a very accurate method of determining the glomerular filtration rate was required. This highly accurate, but very expensive assay correlated with the mathematical formula that has since been used to estimate the GFR. This study takes into account variations in body size based upon age, race and gender. It is recommended that the MDRD GFR always be reported by the laboratory, and thus should be performed on each patient whenever kidney disease is suspected or during screening. The formula is available at http://mdrd.com, and at http://nephron.com . The MDRD GFR has been adapted as the standard in classifying kidney disease by the worgroups of the Kidney Disease Outcomes Quality Initiative (K/DOQI) sponsored by the National Kidney Foundation.
2. Many patients who develop CKD usually have family members who also have the disease, and they should should be assessed for risk factors. The patient with documented CKD should always be questioned about relatives who may also have the disease.Table 3lists the potential risk factors for developing CKD. Screening includes blood pressure, creatinine, urinalysis and urine albumin creatinine ratio. When CKD is suspected a renal ultrasound should be performed. When the disease is discovered, you primary physician may ask you to see a nephrologists. The nephrologist is a kidney specialist, and will work together with your to determine the diagnosis, if not already made, and particularly if other than hypertension or diabetes. Doctors are always looking to find diseases or components of disease that can be treated.
3. After identifying and staging a patient, an action plan should be developed by your doctor. The plan for stages 1 and 2 (GFR > 60 cc/min) should emphasize preventive measures. Here, your doctor may want to maximize the use of converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB therapy), and will want to strictly manage blood pressure and diabetes according to published guidelines. Addition measures during this phase include determining and managing the underlying diseases, emphasize avoidance of nephrotoxic medications, and helping you institute a program to reduce cardiovascular risk factors and their associated co-morbidities. Proteinuria has been documented to be damaging to the delicate filters inside the kidney, and evidence shows that titrating the dose of therapy with ACE or ARB medications will lower the levels of protein that leak across the filter. Though protein restriction is ideal, it is difficult and challenging, but education by a dietitian and determination should help avoid excessive portions of protein containing foods, and enable the curtailing of excess protein intake. In addition patients and members of the hospital phlebotomy team should work together to avoid damage to veins that might be the future site of an AV fistula. "Please be careful with my veins" is a simple handout developed for patients about to have blood drawn or an IV started. This is a very important concept because if the disease progresses, a surgical procedure on an artery and vein in the arm might be required to enable one to undergo dialysis.
4. Stage 3 (GFR < 60 cc/min) reflects advancing disease. Patients who reach Stage 3 have a greater likelihood of progressing, and it is in this phase that the conditions that are associated with kidney disease and the complications associated with decreased kidney function start to manifest. This website will discuss what happens when the kidneys fail, and the treatment options that are available. Anemia, acidosis, low serum albumin and MBD (mineral and bone disease) develop during this and the next stage. Reaching this stage does not mean that efforts to control diabetes and blood pressure should cease or even slow. It is important to remain attentive to problems associated with heart disease, hypertension and diabetes, as it is the complications of these disorders that are most challenging.

Clinical Performance Measures

It is important that physicians, patients and other members of the health team work together to improve the outcomes of patients with kidney disease. Clinical performance is a team effort, and each member of the health care team, including the patient, is in a position to drive good health care.

Clinical performance strategies for patients should include:

Stage 1 and 2

At this stage, it is possible to prevent progression of disease, but it requires effort in five areas:

1. Work with your doctor to establish the correct diagnosis. Help with the screening of family members.
2. Understand the disease
3. Taking medications and avoiding toxins
4. Watching diet and salt
5. Exercise, avoid tobacco (or other substances)

All patients who have Stage 1 or 2 CKD (GFR > 60 cc/min) and beyond should have the objectives of

1. BP < 130/80
2. HgbA1c < 7.0
3. Utilization of an ACE or an ARB medications (or sometimes both)
4. Titration of the urine protein albumin ratio to less than 30
5. LDL and HDL management per ACC Guidelines
6. Pneumococcal vaccine and yearly flu shot
7. Vitamin D level > 50 (may use ergosterol)
8. Diabetic retina examination (if diabetic)
9. Baseline KD Quality of Life Survey
10. Echocardiogram

Please refer to this educational program for additional resources that will help understand why this is necessary.

Renal education is critical to the success of any disease management program/ One should be aware of the objectives of such a program in advance. Disease management for patients should include

1. Dietitian consultation (education regarding excess proteins, saturated fats, excess carbohydrates, sodium restriction, calorie restriction, health food substitutions)
2. How the Kidney Works, What the Kidneys Do and What happens when kidneys fail
3. Medications to avoid
4. Vein preservation
5. Diabetes management (if diabetic)
6. Cardiovascular risk factor management

Stage 3

At this stage, one may start to develop some of the side effects associated with failing kidneys. Also, the complications of diseases that led to kidney disease, like stroke and heart disease are also of concern. Here, patients should work closely with the doctor and provider team to:

1. Assessment for anemia is done by measuring the CBC, ferritin, iron saturation - The target Hgb is 11 - 12 d/dL and institution of appropriate management includes closely monitoring these laboratory values.
2. Serum albumin of 4 g/dL - The albumin is a typle of protein. Its level, when decreased, is mainly a marker of inflammation, rather than nutrition.
3. Electrolytes - for metabolic acidosis and hyperkalemia (medications and diabetes) - Electrolytes are minerals that carry an electric charge. They are needed for body functions, and must be in balance.
4. iPTH level in KDOQI range for stage (Stage 3 - 35-70, Stage 4 - 70 - 110)
5. Vitamin D analog at stage 4 - When the kidney fails it cannot activate vitamin D. Vitamin D has many functions in the body. It regulates the parathyroid glands in the neck, and plays a role in bone growth, cancer, inflammation and muscle function.
6. Titration of proteinuria with an ACE or an ARB - These classes of medications decrease angiotensin, a compound that can raise the blood pressure inside the kidney and also incite damage. Proteins passing across the kidney filter also damage it. The protein loss may be decreased with increased use of an ACE and an ARB or both.
7. Follow up visits for renal education - The patient must be well informed about kidney disease to willingly follow all the rules to stay healthy. Education programs are vital to this education. Therefore, frequent visits to the physician or other provider on the health team are often highly beneficial in optimizing outcomes.
8. Dietitian consult
9. Review of dialysis modalities
10. Vein preservation education
11. Education regarding the avoidance of toxic medications and substances
12. Encourage exercise, cardiovascular risk factor prevention
13. Diabetes management coordinated with the primary care physician

Stage 4

Continued management by the nephrologist of the above plus

1. Electrolytes (K and C0₂ in range)
2. A tour of the dialysis center - Modality education, including transplantation and home dialysis (PD and hemo)
3. KDQOL repeat
4. Vein mapping and referral to a surgeon experienced in placing AV fistulae
5. CKD-MBD management - PTH level, serum Ca and P management
6. Repeat echocardiogram

Disease manager

1. Review of blood pressure medications and patient follow-up to make sure BP < 130/80
2. Review of nutrition, medication, and education objectives, making sure they are being met
3. Follow up assessment of cardiovascular (and diabetes) status, diet and sodium status
4. Follow up and arrangement of KDQOL
5. Modality selection and tour of a dialysis center
6. Liaison between patient, primary physician, nephrologist, health plan medical director