Physicians May Miss Signs of Chronic Kidney Disease

A lot of primary care physicians need to bone up on the signs of chronic kidney disease, according to investigators here.

When randomly selected family practitioners and internists, were asked which diagnostic tests they would order for a hypothetical patient with symptoms and lab values consistent with chronic kidney disease, 59% of FPs and 78% of internists got it right, said L. Ebony Boulware, M.D., M.P.H., and colleagues, of Johns Hopkins.

This contrasted with 97% of nephrologists who got it right when asked the same questions.

“We, as physicians, can certainly do better,” the investigators wrote in the August issue of American Journal of Kidney Diseases.

“Millions of people have kidney disease, but a substantial number may not have their disease recognized,” they added. “Simply put, our study shows that primary care physicians are not recognizing kidney disease in high-risk patients as often as they should.”

I am currently involved in a project aimed at improving the care of CKD in Alabama physicians. We recognize several problems, the most important is making the diagnosis.

The problem stems from our use of serum creatinine. Because serum creatinine is inversely proportional to renal function, many patients have significant loss of renal function before we notice that damage is ongoing.

We decrease the problem when we use estimation equations based on the serum creatinine. Some labs provide estimated GFR along with the serum creatinine. However, the estimation equations are good but have flaws.

Growing data suggest that cystatin C may replace serum creatinine as a measure of renal function. Cystatin C appears to detect decreased renal function earlier than serum creatinine.

Once we make the diagnosis of CKD, many physicians do not have a standard approach to Stage III and Stage IV CKD. While one can find guidelines – K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification – this page contains 15 separate guidelines, each of which is almost indecipherable. In an attempt at completeness, the generalist physician cannot separate the important from the eclectic.

One can easily criticize most guidelines for being over complete. As I read these guidelines, I have worked to develop a personal strategy for patients. However, we cannot expect each physician to go through this process.

In my opinion, diabetes care is improving because we have standards for care. We know what to measure and what our goals of treatment are. While CKD probably is more complex than diabetes, we still need to make CKD care tractable.

Our research project hopes to do that. We hope to develop a criteria list for diagnosis, management and referral in CKD. We must make that list straightforward, understandable and memorable. Then we must work hard to teach that list to physicians.

Physicians would love to take excellent care of their patients. We (the educators) must give them the meat and potatoes and leave the trimmings for consultation. When generalists do not know what to do, then the profession has failed those physicians.

Related posts:

1. 17 days at the VA – Day 4
2. Another performance measure challenged – BP goal
3. Screening for progressive CKD
4. More data on Cystatin C
5. 15 days at the VA – day 2

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