Early nephrology referral is associated with decreased mortality, hospitalizations, and better preparation for dialysis treatment.Indications for referral to nephrology include:
- Acute kidney injury or abrupt decrease in GFR
- GFR <30 mL/minute/1.73 m2 (G stage 4-5)
- Persistent, significant albuminuria
- Progression of CKD with sustained decline in GFR
- Urinary red cell casts or urinary RBC >20 with no apparent explanation
- CKD with hypertension that does not respond to 4 or more antihypertensive agents
- Persistent serum potassium abnormalities
- Recurrent or extensive nephrolithiasis
- Hereditary kidney disease 2,8
Patients require a form of renal replacement therapy for survival once their GFR declines to 5 to 10 mL/minute/1.73 m3. The 3 forms of renal replacement therapy include hemodialysis, peritoneal dialysis, and renal transplant.5 The preferred form of hemodialysis access is the arteriovenous fistula, which may require months to mature before it can be used for hemodialysis. Therefore, it is recommended that patients with CKD establish care with a vascular surgeon within 1 year of requiring hemodialysis, so that construction may be attempted at least 6 months before they are expected to begin hemodialysis.15
How Can I Educate a Patient About Living With CKD?
Patients should be aware of symptoms that may develop because of worsening CKD, such as swelling, hypertension, and fatigue. Providers should inform affected patients that they are at an elevated risk for heart disease, bone disease and fractures, anemia and abnormal blood clotting, and metabolic acidosis. Patients should be informed of the symptoms of uremic encephalopathy mentioned here, and call their clinician immediately after onset of symptoms.21
Providers should emphasize that treatment goals are based on preventing further damage to the kidneys; any existing damage cannot be reversed. Preventative measures include complying with antihypertensive and diabetic medications, as well as monitoring blood pressure and blood sugar appropriately. Dietary changes such as protein, fluid, and salt restrictions should be discussed, and alternative food options should be provided. Providers must counsel patients with CKD on weight loss and smoking cessation when appropriate. Patients must avoid taking nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen, and should consult with their physician before starting any new medication.21
Even in patients with early CKD, a discussion about future renal replacement therapy should occur. The advantages and disadvantages of each of their options should be reviewed so that patients can make an informed choice. Hemodialysis requires a major lifestyle change, as patients must spend hours at a dialysis center 3 times per week, and peritoneal dialysis requires filtration through the patient’s peritoneal membrane and is associated with peritonitis. Kidney transplant results in higher survival rates, but patients often must wait 2 to 6 years.5 Patients should already be in the care of a nephrologist by the time this decision is made, but it is important for primary providers to prepare patients for this early in the disease.
CKD remains a prevalent health issue in the United States and is associated with significant mortality and healthcare costs. Primary care providers play an essential role in identifying the disease early, providing preliminary patient education, and referring the patient to a specialist when appropriate. Clinicians must be aware of high-risk populations, including patients with diabetes mellitus, hypertension, heart disease, high body mass index, and advanced age.5 Patients with CKD are often asymptomatic; therefore, paying close attention to CKD clues on routine laboratory work and screening those with diabetes and hypertension may prevent delayed diagnosis. When a diagnosis of CKD is suspected, estimated GFR and albuminuria measurements must be properly obtained. Primary care providers should familiarize themselves with treatment strategies for CKD and medications that must be adjusted or avoided in patients with CKD, as well as educate patients on the detrimental effects of taking these medications without a clinician’s approval. Providers should not delay referral to nephrology, as early referral is associated with decreased mortality and hospitalizations for patients with CKD.
Natalie Wynn, PA-S, is a student and E. Rachel Fink, MPA, PA-C, is an assistant professor at Augusta University Physician Assistant Program in Georgia.
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