2011 Scientific Assembly Needs Assessment

Body System: Nephrologic

Session Topic: End-stage Renal Disease/Oliguria/Renal Failure/Chronic Kidney

Disease

AAFP Learning Category I: DIDACTIC LECTURE

**SPECIAL REPURPOSING INFORMATION**

This topic has been selected as part of the AAFP Assembly Online series, a special
selection of presentations from the Scientific Assembly. The recorded audio from this
presentation will be synched with the accompanying PowerPoint slides and made
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 5) A set of 5 multiple choice questions and answers is required along with the
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found in.

Needs Assessment
It is estimated that as many as 23 million adults aged 20 or older have physiological
evidence of chronic kidney disease (CKD), accounting for approximately 11.5% of the
adult population.1 However, only 2% (4.5 million adults) have reportedly been told by a
physician within the past 12 months that they had CKD. The 2009 National Health
Interview Survey reported that kidney disease is much more prevalent among poor
adults and those with less education; adults under the age of 65 covered by Medicaid –
and those with less than a high school education – have higher percentages of CKD.2

According to the National Institutes of Health (NIH), “kidney disease can be detected
earlier by standardized blood tests to estimate renal function and monitoring of urine
protein excretion. New drugs better control blood pressure and slow the rate of kidney
damage by about 50%.”3 Family physicians should conduct such blood tests as part of
routine screenings for patients with kidney disease, and many do. AAFP Practice Profile
data indicate that the majority of family physicians perform a variety of blood and urine
tests or collect the specimen and send to an outside lab; such tests include complete
blood count (CBC), Hemoglobin, dipstick urinalysis or urine microscopic exam.4
Screening and diagnosis of patients with CKD can help family physicians to classify
stages in the progression of the disease, which will allow them to better manage such
patients.

The National Kidney Foundation’s Kidney Disease Outcome Quality Initiative (KDOQI)
workgroup defines the criteria for CKD as having:5
• Kidney damage for more than three months, as defined by structural or functional
abnormalities of the kidney, with or without glomerular filtration rate (GFR)
o This may manifest as pathological abnormalities or blood/urine/imaging
markers of kidney disease.
• OR having GFR less than 60 mL/min/1.732 for more than three months, with or
without kidney damage.

Patients are either determined to be at increased risk (defined by GFR greater than 90),
or are stratified into five stages ranging from kidney damage with normal or high GFR to
kidney failure (also known as end-stage renal disease, or ESRD). If the disease
progresses to ESRD, patients are referred for dialysis or consideration for a kidney
transplant.5 However, patients must be considered “medically suitable” for a transplant,
and as such, they undergo an extensive evaluation to determine certain eligibility
requirements, which includes identifying the presence of co-morbid conditions, such
as:6,7
o Hematologic abnormalities such as anemia
 o Upper and lower gastrointestinal tract abnormalities (such as gastritis, peptic
ulcer disease or diverticular disease)
o Viral hepatitis B or C
o Cardiovascular diseases or conditions such as hypertension or past myocardial
infarction
o Infections such as tuberculosis or osteomyelitis

Transplantation may also not be recommended for patients with a history of cancer,
immune dysfunction or generally unhealthy lifestyles (such as smoking or alcohol or
drug abuse).7 Alternative treatment options (such as dietary modifications and certain
medications) and end-of-life care should therefore be discussed with patients who not
qualify as kidney transplant recipients or who choose not to undergo hemodialysis. As
with other progressive and life-threatening illnesses, family physicians are uniquely
positioned to initiate important communication with patients and their families as they
approach ESRD. They can help patients and family members/caretakers to select
appropriate palliative care options when necessary, as well as guide them through the
complexities of the healthcare system. Because the rates of ESRD are much higher
among black and Native American populations,6 family physicians should exercise
culturally competent care in all interactions with patients and families as well.

According to the National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK), the five primary diseases causing end-stage renal disease (ESRD) were
diabetes, hypertension, glomerulonephritis, cystic kidney and urologic diseases.1
Current clinical practice guidelines recommend including treatment of co-morbidities
(specifically for cardiovascular disease) along with treatment of CKD to slow the
progression of the disease and prevent complications.5 If caught early enough, it may
be possible to restore some kidney function using more aggressive treatment and
management of conditions such as diabetes, hypertension and advanced forms of
cardiovascular disease. Thirty years ago, one-third of diabetic patients were destined to
develop kidney failure; now, fewer than 10% of diabetic patients with good care develop
kidney failure, presumably because of enhanced methods of screening, diagnosis and
treatment that have led to earlier interventions for kidney disease.3

Because family physicians are well positioned to manage a variety of comorbidities in

patients of all disease states, they should be prepared to assess, treat, and, if possible,
prevent conditions that can lead to or complicate CKD. These include dyslipidemia,
anemia, renal osteodystrophy, uremia, poor nutrition and smoking. As patients develop
more progressive damage to their kidneys, they frequently experience disruptions to
their lipid/blood/protein levels in addition to changes in bone structure and mineral
metabolism.8 Management of these conditions frequently requires family physicians to
review and revise patients’ medications. Dosing may need to be adjusted according to
the patient’s level of kidney function, and detection should be done of drug interactions
and potentially adverse effects on kidney function (or complications of CKD).5,8

Anemia is a common complication of CKD and ESRD, and although therapeutic options
primarily focus on treatment of kidney disease, erythropoietin-stimulating agents may be
indicated for use in some patients. It should be noted, however, that the use of such
agents remains controversial; some studies report a poor response to treatment,
significant side effects and decreased long-term effectiveness (in some cases, even
shorter survival rates).9,10 Erythropoietin-stimulating agents can increase blood pressure
and the risk for thromboembolic complications; hemoglobin levels should also be
checked monthly during therapy, and iron supplementation may also be warranted for
patients undergoing treatment.11

Treatment for even moderate anemia is usually indicated in patients with chronic illness,
including older adults. While some exceptions may apply to extremely ill patients or
those at the end of life who decline therapeutic interventions, one source notes that
even “in patients with renal failure who are receiving dialysis and in patients with cancer
who are undergoing chemotherapy, correction of anemia up to hemoglobin levels of
12g/dL is associated with an improvement in the quality of life.” Some research has
shown that patients with end-stage renal disease, for example, experience benefits from
iron treatment to improve hemoglobin levels.10 Further, the KDOQI guidelines
recommend that patients with anemia of CKD should aim to receive therapy that places
hemoglobin targets within 11 to 12 g/dL, not to exceed 13g/dL.12 It should be noted,
however, that ongoing research into the safety and effectiveness of treatments for
patients with anemia of chronic disease is being conducted.

Because of the high prevalence of kidney disease in the U.S., and the rising number of
patients that family physicians see with CKD, especially related to conditions such as
diabetes and hypertension, it is imperative that they be familiar with the KDOQI
guidelines for classifying patients in order to begin appropriate interventions. In cases
where patients require referral to sub-specialists for advanced testing, evaluation or
treatment (including hemodialysis or kidney transplantation), family physicians are
uniquely positioned to orchestrate patient care, assist family members/caregivers with
guidance and resources needed to navigate complexities of the healthcare system, and
provide ongoing treatment and follow-up.

Gaps in Knowledge, Competence and/or Performance:

• In order to properly assess patients with chronic kidney disease, family
physicians should be familiar with the most current definition of CKD and criteria
for stratifying patients into appropriate stages of the disease.
o Family physicians should be familiar with the National Kidney
Foundation’s Kidney Disease Outcome Quality Initiative (KDOQI) and its
guidelines for identification, treatment and management of CKD.
• With the rates of chronic conditions such as hypertension and diabetes on the
rise, family physicians should offer treatment options for patients with such
conditions to prevent the development of CKD or renal failure.
o Clinical interventions that can be staged include helping patients control
blood glucose levels and high blood pressure, incorporating healthy foods
into their diet and initiating smoking cessation.
 • Family physicians should be aware of effective therapeutic options for patients in
varying stages of CKD – including those with certain comorbidities such as
cardiovascular disease or anemia – that impact the progression of the disease.
Doing so will allow family physicians to start patients on appropriate interventions
and ultimately help to prevent ESRD as well.

Learning Objectives:
At the end of this session, participants will be able to:
1. Incorporate the major points of the National Kidney Foundation Quality
Outcomes Initiative for chronic kidney disease (CKD) into practice.
2. Accurately identify, screen, evaluate and classify patients who are at risk or have
the diagnosis of CKD.
3. Reduce the risk for progression of CKD to ESRD by applying appropriate, proven
therapeutic interventions early in the disease process.
4. Compare management strategies for anemia, bone disease, malnutrition, and
electrolyte abnormalities in the later stages of CKD.

References:

1. Kidney and Urologic Diseases Statistics for the United States. National Kidney and Urologic
Diseases Information Clearinghouse (NKUDIC). National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDKD). Available at
http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/index.htm

2. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009 CDC Vital and
Health Statistics, Series 10, No. 249 National Center for Health Statistics. August 2010. Available
at http://www.cdc.gov/nchs/data/series/sr_10/sr10_249.pdf

3. Chronic Kidney Disease and Kidney Failure. National Institutes of Health (NIH) Fact Sheet. March
2009. Available at http://www.nih.gov/about/researchresultsforthepublic/kidney.pdf

4. Practice Profile II Survey. American Academy of Family Physicians (AAFP). November 2009.

5. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification and
Stratification. Kidney Disease Outcome Quality Initiative (KDOQI). National Kidney Foundation,
2002. Available at http://www.kidney.org/professionals/KDOQI/guidelines_ckd/p1_exec.htm

6. Kaufman D. Renal transplantation (Medical). eMedicine Transplantation. April 2010. Available at

http://emedicine.medscape.com/article/429314-overview

7. Kidney Transplant. MedlinePlus Medical Encyclopedia. National Library of Medicine. June 2009.
Available at http://www.nlm.nih.gov/medlineplus/ency/article/003005.htm

8. Snively C, Gutierrez, C. Chronic Kidney Disease: Prevention and Treatment of Common

Complications. Am Fam Physician. 2004;70:1921-1928,1929-1930. Available at
http://www.aafp.org/afp/2004/1115/p1921.html
 9. Bross M, Soch K, Smith-Knuppel T. Anemia in Older Persons. Am Fam Physician
2010;82(5):480-487. Available at http://www.aafp.org/afp/2010/0901/p480.html

10. Weiss G, Goodnough L. Anemia of Chronic Disease. NEJM 2005;352:1011-23.

11. Weiss B, ed. Common Renal Conditions. FP Essentials™ 375, AAFP. August 2010. Leawood,
Kan.

12. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in
Chronic Kidney Disease: 2007 Update of Hemoglobin Target. National Kidney Foundation. 2007.
Available at http://www.kidney.org/professionals/KDOQI/guidelines_anemiaUP/index.htm

AAFP Learning Category I: DIDACTIC LECTURE