Management of chronic kidney disease
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7499.1039 (Published 05 May 2005) Cite this as: BMJ 2005;330:1039
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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
President, The Renal Association
Chairman, Joint Specialty Committee on Renal Disease of the Royal College
of Physicians and the Renal Association
The John Walls Renal Unit,
Leicester General Hospital,
Gwendolen Road,
Leicester LE5 4PW
jf27@le.ac.uk
1. Frankel A, Brown EA, Wingfield D. Management of chronic kidney
disease. BMJ 2005. 330(7499): p. 1039-40.
Competing interests:
None declared
Competing interests: No competing interests
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
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/
PublicationsPolicyAndGuidance/PublicationsPAmpGBrowsableDocu
ment/fs/en?CONTENT_ID=4102941&chk=aKHxDl
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.
Competing interests: No competing interests
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
Head of Nephrology Department
Hospital Dr. Gustavo Aldereguía Lima,
Cienfuegos, Cuba. Nefro@gal.sld.cu
Prof. Alfredo Espinosa-Brito, MD, PhD
Internal Medicine Department
Hospital Dr. Gustavo Aldereguía Lima,
Cienfuegos, Cuba.
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
Competing interests: No competing interests
Proteinuria should be treated per se in patients with CKD
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
Competing interests: No competing interests