Primary care physicians play a pivotal role in preventing kidney disease progression, yet routine screening and clear communication remain inconsistent.
Jay H. Shubrook, D.O.
Professor, Primary Care Department, Touro University California
What are the biggest gaps in identifying and managing kidney disease in primary care?
There are numerous important opportunities for us to improve kidney disease management in clinical care. Primary care providers (PCPs) see the most people with kidney disease, but the visit is rarely focused on this.
PCPs should incorporate asymptomatic screening of kidney disease in high-risk people. This starts with all people with hypertension or diabetes mellitus. Screen with both a blood and urine test. While most people at risk for kidney disease have had a blood test to check for the kidney flow, only about half have had the urine test to check the filtering capacity of the kidneys. Be clear in your communication with your patients. Often, we may soften our language or minimize abnormalities in order not to worry the patient. This only delays action to prevent further testing or treatment. Too many people find out that they have kidney disease at the time that they need renal replacement or have a complication of kidney disease.
Many people do not know that the diagnosis of chronic kidney disease (CKD) does not mean an inevitable decline to dialysis. In fact, only about 10% will ever need renal replacement therapies like dialysis. However, CKD increases the risk for cardiovascular disease, bone disease, hypertension, and heart failure. We have a lot we can do to help prevent the progression of kidney disease and in certain cases help to reverse some of the damage. However, this is only possible if you seek care and get testing done.
Which early signs or risk factors should primary care physicians watch more closely?
Probably the most important thing I can share here is that the most common early symptom is: nothing. Early kidney disease is silent and is found on screening blood and urine tests. Please do not wait for late symptoms like urinary changes, fatigue, or itching.
How can routine screening be improved to catch kidney disease earlier?
We need a national campaign. Know your kidney numbers. Since so many adults in the United States have more than one chronic disease, it is likely that most adults should have this screening at least annually. Since it involves blood and urine tests, we need PCPs to order them and strongly encourage the patients to get them done.
What impact does early intervention have on outcomes, and what practical steps can PCPs take now?
We can take several steps to prevent kidney disease and manage it once it occurs.
- We can educate our patients about the diagnosis and all that can be done to prevent progression (This can combat fatalism regarding CKD.)
- Maintaining a healthy weight or reducing excessive weight helps the kidneys.
- Stabilizing blood pressure and glucose really helps to prevent CKD.
- Ask patients to check in with your medical team to make sure they are getting screened and that anything abnormal is explained to them and rechecked.
- Many treatments help people with CKD:
- Blood pressure medications like ACE inhibitors and ARBs help.
- If they have diabetes mellitus, use of SGLT-2 inhibitors and GLP-1RA can help reduce the risk of progression and heart disease.
- There are other medications, such as finerenone, that provide benefits for both the kidney and the heart.
- Smoking cessation helps all of these conditions.
- Staying physically active and maintaining a healthy diet helps as well.
- Encourage the patient to talk to other people who have been successful in preventing progression. They will not have to look hard; there are many. This will help patients to overcome fatalism and to be empowered to take control of their kidney health.
- Both PCPs and patients should be mindful of watching for medications that can affect the kidneys. Making informed decisions can help from overmedicating.
- Please give your patients the opportunity to be involved in the prevention and treatment of CKD. Screen them based on the guidelines, communicate risk and disease clearly, and be an ally to help the patients be in charge of their kidney health.
