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Management of chronic kidney disease and chronic kidney failure in Cienfuegos, Cuba.
- Pedro L. Muñiz Olite, Prof. Alfredo Espinosa-Brito, MD, PhD (11 May 2005)
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Chronic kidney disease is a disease of older people and this should be taken into account when setting up a model of care for patients with this disease
- Shelagh E O'Riordan (20 May 2005)
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Managing Chronic Kidney Disease
- John Feehally (24 May 2005)
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Proteinuria should be treated per se in patients with CKD
- Michel Y Jadoul (28 May 2005)
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Pedro L. Muñiz Olite, Head of Nephrology Service University Hospital, Prof. Alfredo Espinosa-Brito, MD, PhD
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Increasing prevalence, severe physical and social disabilities, high cost of care and elevated mortality rates characterize chronic kidney failure (CKF) as a condition with dramatic consequences from the medical, social and economic points of view, all over the world. (1,2) In Cuba the prevalence has been calculated as 3.5 patients per 1 000 inhabitants in general population. For those who are in any chronic dialysis treatment, 149 patients were reported per 1 000 000 inhabitants, in 2004. (3) In Cienfuegos, our province, national guidelines have been adopted for the medical care of this complex group of patients. Those guidelines are based on a very closed work interaction between primary and secondary care, as a real system. Risk factor prevention for chronic kidney diseases (CKD) and their control are important tasks for family physicians at primary care level in our country. They also care and follow up patients with CKD but without CKF (glomerular filtrate > 89 ml/min/1,73m2), but in this case, nephrologists from secondary care periodically advice primary care doctors. When any reduction of glomerular filtrate is detected (< 90 ml/min/1,73m2), patients are referred to a specialized and multidisciplinary consultation at secondary care, where doctors, dieticians, specialists in rehabilitation, psychologists and specialized nurses evaluate them. If glomerular filtrate is between 30 and 89 ml/min/1,73m2, measures directed to control “basic” clinical conditions and retardation disease progression are essential. When glomerular filtrate is between 15 and 29 ml/min/1,73m2, the patient is prepared for dialysis. Without doubt, in caring for these patients greatest efforts have to focus on high risk groups for CKD, on those who suffer CKD but normal glomerular filtrate and on those with initial stages of CKF (glomerular filtrate between 30 and 89 ml/min/1,73m2), because we can obtain better outcomes in disease stopping with appropriate management. Finally, we think that good results in this field can be fulfilled only if there are strong work links between primary and secondary medical care. In other words, if there is a correct projection of nephrology to the community. Sincerely, Pedro Muñiz-Olite, MD
Prof. Alfredo Espinosa-Brito, MD, PhD
References: 1. Schieppati A, Perico N, Remuzzi G. Preventing end-stage renal disease: The potential impact of Screeing and intervention in developing countries. Nephrol Dial Transplant 18: 858-859, 2003. 2. Kazmi WH, Obrador GT, Khan SS, Pereira BJG, Kausz AT. Late Nephrology referral and mortality among patients with end-stage renal disease: apropensity score analysis. Nephrol Dial Transplant 19:1808-1814, 2004. 3. Instituto de Nefrología. Grupo Nacional de Nefrología. Coordinador Nacional de Enfermedad Renal Crónica, Diálisis y Trasplante. Indicadores estadístico del programa nacional de nefrología en Cuba. Año 2004. Competing interests: None declared |
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Shelagh E O'Riordan, Consultant Geriatrician East Kent Hospitals NHS Trust, Kent and Canterbury Hospital, Canterbury CT1 3NG
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Chronic kidney disease (CKD) is a disease of older people. Frankel et al in their editorial on CKD (1) quote Ian Johns study of unreferred CKD (2) in East Kent: 90% of those not referred with CKD were over 70 years and 66% were over 80 years old. This study identified patients with CKD by using clinical biochemistry database: requests for the unreferred group were from geriatricians in over 20% of cases. The National Service Framework for Renal Services Part 2 which was published in February this year (3) (but not referenced in this editorial) has two quality requirements- the first on preventing CKD in those at risk and the second on appropriate treatment of those with established disease. The NSF highlights the needs of the majority of patients with CKD who are older and have co-existing illnesses. It states "they need packages of care which co-ordinate and personalise their treatment, without requiring them to attend different clinics at different times in different places". Any solution, as proposed by Frankel et al, which does NOT [corrected 23.5.05] take into account the older frailer patients with CKD and utilise the expertise of geriatricians with their experience in comprehensive assessment and access to multidisciplinary teams would fail this large but potentially vulnerable group of patients 1. Frankel A, Brown E, Wingfield D. Management of Chronic Kidney Disease. BMJ 2005;330:1039-1040 (7 May), doi:10.1136/bmj.330.7499.1039 2. John R, Webb M, Young A, Stevens PE. Unreferred chronic kidney disease: a longitudinal study. Am J Kidney Dis 2004;43: 825-36. 3. The National Service Framework for Renal Services- Part two:
Chronic Kidney Disease, Acute Renal Failure and End of Life Care
Competing interests: SO'R represented the British Geriatric Society (BGS) on the section on CKD in the NSF for Renal Services and was the BGS representative on the RCP/RA guidelines on Guidelines for identification, management and referral of adults with CKD in the United Kingdom. |
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John Feehally, Consultant Nephrologist Leicester General Hospital LE7 9HU
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The recent editorial by Dr Frankel and colleagues [1] emphasizes the need to develop integration between specialist renal units and their partners in primary care and other secondary care specialties, if we are appropriately to manage the whole gamut of chronic kidney disease [CKD]; and correctly identifies the need for clinical practice guidelines as a basis for the development of care pathways which ensure people with CKD get the right advice, in the right place, at the right time, by the right health care professionals. I am pleased to say that comprehensive, evidence-based clinical practice guidelines on identification, management, and referral of adults with CKD have recently been developed by a working party with representation from the Royal College of Physicians, the Renal Association, the Royal College of General Practitioners, the Association of Clinical Biochemists, the British Geriatrics Society, the Society for District General Hospital Nephrologists, the Professional Advisory Council of Diabetes UK, and the National Kidney Federation. Additional stakeholders whose views were taken into account during the consultation process included the Joint Specialty Committees on Cardiology, General Medicine, and Geriatrics of the Royal College of Physicians of London; and the British Hypertension Society. These guidelines, which are to be published shortly by the Royal College of Physicians, therefore represent a broad national consensus. It is my confident expectation that these guidelines will become a key resource in developing modern management for CKD. Yours sincerely, John Feehally
The John Walls Renal Unit,
Leicester General Hospital,
Gwendolen Road,
Leicester LE5 4PW
1. Frankel A, Brown EA, Wingfield D. Management of chronic kidney disease. BMJ 2005. 330(7499): p. 1039-40. Competing interests: None declared |
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Michel Y Jadoul, Professor, Head of Department of Nephrology B-1200 Brussels Belgium
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The editorial by Frankel and colleagues (1) on the joint management of patients with chronic kidney disease (CKD) by primary and secondary care, is welcome and rightly emphasizes the enormous potential benefits, both medical and economical, of the optimal management of patients with CKD. The authors emphasize the importance of “tight control of blood pressure, correcting lipid abnormalities and various lifestyle changes including the cessation of smoking”. Surprisingly, they do not mention antiproteinuric treatment and thus miss an important opportunity to stress for primary care physicians the major progresses in this field. Proteinuria is indeed not only a risk factor for rapid progression of CKD (2) but also a specific target that should be treated per se (3), both in diabetic and proteinuric non diabetic CKD. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers should be first-line antihypertensive agents and should even be prescribed in the absence of hypertension in patients with proteinuric CKD (4). This will substantially delay end-stage renal disease. Specific guidelines based on a high evidence level have been issued on this topic (5). Primary care teams should thus include in their targets for CKD patients not only tight control of blood pressure, correcting lipid abnormalities and lifestyle changes but also optimal antiproteinuric treatment. Professor M. Jadoul, M.D. Cliniques Universitaires St Luc Department of Nephrology Université catholique de Louvain B-1200 Brussels, Belgium Ph :32/2/7641852 Fx :32/2/7642836 Email :jadoul@nefr.ucl.ac.be References: 1. Frankel et al. Management of chronic kidney disease. BMJ 2005; 330: 1039-1040. 2. De Jong PE et al. Renoprotective therapy: titration against urinary protein excretion. Lancet 1999; 354: 352-353. 3. Levey AS. Nondiabetic kidney disease. N Engl J Med 2002; 347: 1505- 1511. 4. Jafar TH et al. Angiotensin-converting enzyme inhibitors and progression of nondiabetic renal disease. Ann Intern Med 2001; 135: 73- 87. 5. K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Am J Kidney Dis 2004; 43 (suppl. 1): S1-S290. Competing interests: None declared |
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