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You may be a Hotel Operator, a Hotel Supplier or a Hotel Consultancy Organisation looking for new endeavours. If you are any of them and wish to participate in the project, we would be pleased to hear from you. From the Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, VA. The prevalence of chronic kidney disease (CKD) in the United States has reached epidemic proportions [1–4].
Screening for CKD is done with measurement of blood pressure and serum glucose, urinalysis (including microscopy), measurement of albumin-to-creatinine ratio in a spot urine sample (proteinuria), and estimation of the GFR.
Timely identification of CKD is inevitably linked to the clinical methods of measuring or monitoring renal function. Optimal therapy of CKD focuses on treatment of the primary disease and comorbid conditions, attempts to prevent progression of CKD and complications of CKD, and maintenance of a good quality of life [5,14]. Initial evaluation of anemia includes a blood smear and assessment of iron stores, reticulocyte count, mean corpuscular volume, serum folate, and serum vitamin B12 levels. Treatment with recombinant erythropoietin should be started only after a thorough evaluation has been conducted (as noted above) and the patient has been adequately treated for other treatable causes of anemia. Poor control of secondary hyperparathyroidism is associated with many clinical problems (Table 3) and increased mortality [41]. The lower the serum albumin level at initiation of dialysis, the greater the risk of increased length of hospital stay, cost, and mortality rate [5]. Overt proteinuria and even microalbuminuria are risk factors for CKD and kidney disease progression. The various clinical practice guidelines provide evidence-based direction for treating patients with CKD. Mortality rates are still unacceptably high despite improved technical and medical knowledge in the care of patients with end-stage renal disease (CKD stage 5).
Kidney damage is identified as structural or functional abnormalities of the kidneys (eg, with radiologic imaging) or abnormal composition of blood or urine.
These tests are readily available, relatively inexpensive, and already performed widely in primary care physicians’ offices. Despite its widespread use for the past decades, serum creatinine concentration alone is an inadequate indicator of renal function, especially in the elderly.
The clinical course of CKD is variable and dependent on concurrent comorbidities and the stage of CKD.
Effective glycemic control is imperative in CKD patients to reduce the renal complications of diabetes. Iron deficiency is common in CKD patients due to poor nutrition and increased need of iron for erythropoiesis. Improved hemoglobin concentration in anemia of CKD has been associated with improved quality of life, including decreased hospitalizations, decreased length of stay in hospitals, and decreased costs [15]. Deficiency of vitamin D, retention of phosphorus, and elevation of the calcium-phosphorus product and parathyroid hormone (PTH) levels (secondary hyperparathyroidism) are common as CKD progresses to stage 3 and beyond.
Vitamin D supplements are recommended to prevent hypocalcemia and decrease PTH, provided phosphorus levels are normal. Malnutrition, proteinuria, and chronic inflammation are common causes of hypoalbuminemia in CKD patients.
They are applicable in the primary care setting but are time-consuming and complex to implement.
Efforts to reduce morbidity and mortality in CKD patients have focused on improving care in the earlier stages of disease. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Please read on, and if you think that your professional standards are of the level required there, please contact us. Efforts to decrease the morbidity and mortality observed with end-stage renal disease have focused on improving care in the earlier stages of kidney disease.


Renal Data Systems, more than 412,215 patients were receiving renal replacement therapy for ESRD as of December 2001 [6].
It has been suggested that all patients with CKD be diagnosed as such and terms like “insufficiency,” “chronic renal failure,” and “renal dysfunction” be avoided [5].
Patients with one or more risk factors for CKD (Table 1) should be screened at least once every year. Inulin clearance is the gold standard for measuring GFR, but this method is seldom used in clinical practice because it is cumbersome and costly [16]. Across all stages, patients are more likely to die of cardiovascular disease than to progress to ESRD [24]. If indicated, other reasons for anemia should be sought, including blood loss, malignancies, dysplastic disorders, chronic inflammatory diseases, and HIV infection. Other positive effects of higher hemoglobin levels include improved energy, appetite, mood, and sex life.
Aluminum hydroxide is best used only for short periods (no more than 4–6 weeks) because of the potential of aluminum toxicity. Citrate treatment should never be used with aluminum phosphate binders as citrate increases enteral absorption of aluminum and can contribute to aluminum toxicity.
Optimal timing of initiation of collaboration thus remains a decision of the primary care physician. Thus, primary care physicians can play a critical role in achieving better outcomes in this group of patients.
Forecast of the number of patients with end-stage renal disease in the United States to the year 2010. The measurement of tubular excretory mass, effective blood flow and filtration rate in the normal human kidney. Amore accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation.
A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine.
Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
The anemia of chronic renal failure: pathophysiology and the effects of recombinant erythropoietin.
Hematocrit level associated mortality in hemodialysis patients, by Ma JZ, Ebben J, Xia H, Collins AJ. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. Early referral to the nephrologist and timely initiation of renal replacement therapy: a paradigm shift in the management of patients with chronic renal failure. The pattern of referral of patients with end-stage renal disease to the nephrologist—a European survey. These efforts seek greater involvement from primary care physicians, who have a critical role to play in early identification, treatment, and appropriate referral of patients with CKD.
Diabetics, patients with family history of kidney disease, African Americans, and hypertensive patients are at particularly high risk [15]. Clearance of endogenous creatinine (24-hour urine collection) has been used, but this method frequently overestimates GFR and is becoming obsolete based on studies that have shown that various prediction equations are convenient and more accurate for assessing GFR [17,18].
For patients who survive, those in stages 4 and 5 are very likely to progress to ESRD [19]. Blood pressure should be checked at every clinic visit even after it has been brought down to goal.
For every 3% increase in hematocrit up to normal (men, 41%–50%; women, 35%–45%), there is a 10% decrease in risk of death [27–33].
In addition, there may be stabilization and possibly regression of left ventricular hypertrophy [15]. Sevelamer is a relatively new binder that does not contribute to metal accumulation and has a desirable effect of lowering low-density lipoprotein cholesterol [40].


The initial consultation is best done no later than stage 3 of CKD based on accumulating evidence that shows that initiating the collaboration later is associated with more metabolic abnormalities, prolonged hospitalizations with higher costs, and increased mortality [4,43–49]. Optimal care of CKD patients includes appropriate screening and early recognition and management of CKD by primary care physicians along with informed collaboration with a nephrologist. Multiple clinical practice guidelines are available to guide primary care physicians in identifying patients with CKD and in initiating therapy, which includes treatment of the primary disease and comorbid conditions, interventions to prevent progression of kidney disease and complications of CKD, and interventions to maintain a good quality of life. Incident rates adjusted for age show that patients over age 65 years are the fastest growing cohort of new ESRD patients [6]. The most popular prediction equations are the MDRD formula (adults < 70 years) (from the Modification of Diet in Renal Disease trial), the Cockcroft-Gault formula (all adults), and the Schwartz formula (children) [19–21] (Figure 1). Presently, there is less information available in the literature about the clinical course of patients in earlier stages (stage 3 and below).
Intravenous iron supplementation is often preferred because up to 1 g of iron is needed to raise the hematocrit from 25% to 35% [34,35]. The rate at which the hematocrit rises should be monitored weekly until the patient’s condition is stable; hypertension, seizures, and venous thrombosis can occur when hematocrit rises too rapidly. The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, are the initial drug of choice for treatment of elevated low-density lipoprotein cholesterol. Edema-free body weight is the weight at which there is no significant peripheral edema on physical examination and there is no clinical or laboratory evidence of dehydration (eg, orthostasis or prerenal azotemia). All patients who have reached stage 4 should be seen by a nephrologist and a team approach to care should be taken [7,50]. Evidence-based guidelines available from the NKF and RPAcan guide care across the continuum of CKD.
In 2000, the average yearly cost of treatment for each patient with ESRD was approximately $68,000 [7]. The prediction equations are readily available on personal digital assistant software and on various sites on the internet [22,23]. The angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are the preferred agents for blood pressure control in patients with CKD (especially with any evidence of proteinuria), heart failure, or diabetes as they not only effectively lower blood pressure but also have renoprotective effects [8].
Timely initiation of collaboration with a nephrologist will facilitate early counseling about modalities of renal replacement therapy and appropriate evaluation for hemodialysis vascular access placement or renal transplantation.
Despite improvements in dialysis and transplantation medicine over the past 40 years, mortality rates in ESRD remain in the 20% to 25% range [6]. A national effort is underway to have clinical laboratories routinely report estimated GFRs [22].
Recent efforts to decrease ESRD morbidity and mortality have focused on identifying patients at earlier stages of CKD and providing interventions to delay the progression of kidney disease [5,8–14]. If additional blood pressure control is needed, second- and third-generation ? blockers are preferred for their antioxidant and heart protection properties.
Improved anemia of CKD has been reported in patients who were switched to intravenous iron after failure of oral iron therapy [36]. Dietitians are an invaluable resource in providing patient education and recommendations about phosphorus binders. These efforts require greater involvement from the primary care physician, who can play a critical role through early recognition and treatment of patients with CKD as well as informed collaboration with a nephrologist once a referral is made.
Lifestyle and dietary changes, including increased physical activity, smoking cessation, and a low sodium diet are recommended. Current treatment guidelines that support the primary care physician in providing care to patients with CKD are available from the NKF and the Renal Physicians Association (RPA). NKF and RPAguidelines are the most widely used in the United States, and more than a dozen sets of guidelines from these organizations provide extensive information in multiple areas. However, the application of these guidelines in clinical practice can be limited by their length (each approximately 200 pages) and complexity. In this article, we present a distillation of NKF and RPA guideline recommendations on the identification and management of CKD.



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