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Primary care doctors should be alert to potential chronic kidney disease in diabetic, hypertensive, and minority patients

Many patients seen by primary care doctors have chronic kidney disease (CKD), with over 6 million Americans having as little as 60 percent of their kidney function. Minorities and people with high blood pressure or diabetes are most at risk for developing CKD. Effective treatment during the early stage of CKD, when patients usually have no symptoms, can delay kidney failure among high-risk groups.

Despite widespread availability of clinical practice guidelines, physicians fail to diagnose and treat this condition, according to Joseph A. Coladonato, M.D., and his colleagues from Duke University. Dr. Coladonato's work was supported by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00079).

In a recent journal article, the researchers recommend ways to improve CKD diagnosis and treatment. They suggest that doctors identify and screen at-risk patients by measuring serum creatinine levels, a common measure of kidney function. However, clinicians should not overlook serum creatinine levels that fall within the normal range for patients who are at high risk for CKD. Specifically, physicians should calculate creatinine clearance using a method that takes into account the increase in creatinine produced with increasing weight and the decline in production associated with age and female sex.

After CKD is identified, doctors should focus on maintaining patient blood pressure and glucose at recommended levels and use angiotensin converting enzyme (ACE) inhibitors and/or angiotensin-receptor blockers, which lower blood pressure and modify abnormal protein trafficking, which is angiotensin-dependent. All patients with evidence of renal impairment and/or proteinuria (high levels of serum protein) should be considered for ACE inhibitor therapy and evaluation by a nephrologist. Doctors also should identify urinary outflow obstruction among CKD patients and minimize their exposure to nephrotoxic agents like nonsteroidal antiinflammatory medications, which increase the risk of acute renal failure.

More details are in "Strategies to enhance detection and treatment of unrecognized chronic kidney disease," by Dr. Coladonato, M.D., Lynda A. Szczech, M.D., M.S.C.E., and William F. Owen, Jr., M.D., in the August 2001 Journal of Clinical Outcomes Management 8(8), pp. 34-40.

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