For Primary Care Physicians

The Nephrology community desperately needs attention and help from Primary Care Physicians because Chronic Kidney Disease (CKD) is not being recognized or treated. Awareness of early-stage CKD is low in the United States, and we are facing an epidemic.

Primary care practitioners have a key lifesaving role in detecting chronic kidney disease. CKD is common, harmful, and –most importantly-treatable. PCPs need to identify CKD early and then assess and optimize cardiovascular status of CKD patients by aggressive treatment of cardiovascular risk factors. Consult with a nephrologist as needed.

• Most practices screen fewer than 20% of their Medicare patients with diabetes
• Patients are referred late to a nephrologist, especially African-American men
• Less than 1/3 of people with identified CKD get an ACE Inhibitor
• Estimated prevalence of CKD is 11%
• 20 million adults (1 in 9) have CKD
• 20 more million are at increased risk
• Estimated prevalence of CKD in King County is 147,679
• Most people with CKD are unaware of the disease
• Patients with CKD are often under-diagnosed despite the fact that economical, effective testing and treatment exist

Chronic Kidney Disease and Cardio-Vascular Disease

Most patients with CKD die from CVD before they develop kidney failure. Cardiovascular outcomes worsen with CKD progression.

CKD patients = highest CVD risk category
• CKD uniquely exacerbates CVD
• CVD risk factors accelerate CKD
• Majority of new patients with kidney failure have CVD
• Most CKD patients die of CVD before Kidney Failure
• Patients with CKD should be treated for CVD risk reduction

Early identification of CKD protects the heart:
• Assess all patients for presence of CKD risk factors
• Screen all patients with CKD risk factors for CKD
• Evaluate all CKD patients for CKD complications
• Treat CKD-associated abnormalities both to optimize cardiovascular status and to slow CKD progression and kidney failure

Patients with risk factors:
• Diabetes
• Hypertension
• Relative with diabetes, HTN, or kidney disease
• Cardiovascular disease
• Metabolic Syndrome
• Age>60
• Nephrotoxic drug exposure including NSAIDS
• Ethnic minority

Which patients should be treated:
• All individuals should be assessed for CKD risk factors upon their initial medical encounter
• Individuals with one or more CKD risk factors should be tested for CKD

Screen All Patients with CKD Risk Factors for CKD
• Blood Pressure Measurement
• Estimate GFR from serum creatinine using the MDRD prediction equation
• Urine microalbumin with a microalbumin dipstick or “Spot” urine albumin to creatinine ratio or standard dipstick

24 hour urine collections are NOT needed.


At what level of creatinine does a 65-Year-Old diabetic, hypertensive white woman weighing 50 kilograms have CKD?

• 77% said:
Creatinine > 1.5 mg / dl

• Creatinine = 1.0 for GFR = 59 mL/min/1.73 m2

Estimated Glomerular Filtration Rate (eGFR)

• The best method available for most people to assess total kidney function
• Can be calculated using the MDRD prediction equation which factors in the following:
– Serum creatinine, age, gender, race, normalized to average adult surface area of 1.73m2
– The MDRD equation has been validated in diabetic and non-diabetic kidney disease, kidney transplant recipients, African Americans and Caucasians with CKD

Automatic eGFR reporting by labs in our region:

• Dynacare (LabCorp)
• Group Health
• Seattle VA
• Providence Everrett
• St. Josephs, St. Francis, St. Clare
• Providence Centralia
• Providence St. Peters

The following labs do NOT offer automatic eGFR reporting :

• Evergreen
• Overlake
• Stevens
• University of Washington
• Harborview Medical Center
• Virginia Mason

Evaluate all CKD patients for CKD complications:

• CVD HTN, Proteinuria, (volume overload-may be present at any eGFR)
• Anemia, Metabolic Bone Disease, Acidosis, Hyperkalemia, Malnutrition, Neuropathy-often develop once eGFR less than 60ml/min/1.76m2
Cardiovascular Risk Factors Associated with CKD
• HTN…………………ACEI/ARB/ BP<130/80/Less than 2000 mg of sodium
• DM…………………..HbA1C<7.0
• Hyperlipidemia……..Statin LDL<100
• Microalbuminuria….ACEI/ARB
• Proteinuria………….ACEI/ARB/ Avoid High Protein Diet
• Volume Overload…...Diuretics/Diet
• Lifestyle……………...Smoking Cessation/Exercise/ Target Ideal Body Weight

All patients should receive CKD education including how to avoid nephrotoxins (i.e. NSAIDS)

Consultation with a Nephrologist should be considered:

• GFR<30ml/min/1.73m2(stage 4)  (refer for RRT preparation & transplant evaluation)
• Rapid progression
(loss of GFR>4 ml/min/1.73m2 per year)
• Diagnosis is unclear
• Co-managing of CKD complications
• Proteinuria >1g per day
• Difficulty controlling blood pressure

For more information, please call or email :

Dr. Leanna Tyshler,
Medical Advisor to the Northwest Kidney Centers
206.292.2771, ext 3086
tyshlerl@nwkidney.org