Letter to the Editor
Letter to the Editor
The comments below are in response to the article "Early Referral of the Chronic Kidney Disease Patient is Good Practice," by Rahul Gupta, MD, MPH, FACP, which appeared in the Jan. 29, 2012, issue. The comments from two of our editorial board members represent somewhat differing perspectives on the role of the primary care clinician in the management of chronic kidney disease. Obviously there is great opportunity for improvement in this area and those of us in primary care are in a unique position to optimize outcomes. Stephen Brunton, MD, Editor
Comment: I take exception with the article "Early Referral of the Chronic Kidney Disease Patient is Good Practice," by Rahul Gupta, MD, MPH, FACP. Of course early referral will have a better outcome than late referrals, but what about the middle and what about primary care physicians managing patients with mild-to-moderate disease? If I referred all my patients with a creatinine above 1.2 (women) and 1.5 (men), I would overwelm the nephrologists. When I look at the nephrology notes on these patients, it is basic primary care. We manage mild-to-moderate hypertension, dyslipidemia, diabetes, CHF, etc., why not kidney disease! This area is a weakness in primary care that should be corrected. We should be managing those patients with eGFR between 30 and 60, and CME tools like Internal Medicine Alert and our conferences should be educating us to do that rather than telling us to refer these patients. Joseph E. Scherger, MD, MPH, Vice President, Primary Care, Eisenhower Medical Center, Clinical Professor, Keck School of Medicine, University of Southern California
Response: Early nephrology referral as part of an interdisciplinary approach in the management of chronic kidney disease (CKD) in primary care may signal an evidence-based paradigm shift. Over the past two decades or so, abundant data have emerged highlighting the fact that optimal pre-end-stage renal disease care involves early interventions aimed at delaying progression of chronic kidney disease, skillful management of other coexisting diseases, timely placement of vascular access and initiation of renal replacement therapy as well as implementation of educational programs targeted at improved rehabilitation.1,2 Studies have long demonstrated that compared to those referred late, early referral of CKD patients may be associated with significant mortality and morbidity benefits.3-5 Additional benefits of optimal predialysis care are also likely to lead to less frequent and shorter hospital stays resulting in lower overall costs, more informed selection of dialysis modality, and non-emergent initiation of dialysis. As early as 1993, the National Institutes of Health issued a consensus statement recommending that referral of a patient to a renal team should occur at a serum creatinine of 1.5 mg/dL in women and 2.0 mg/dL in men.6 However, the preference for early collaboration with a nephrology team should be viewed as an opportunity to implement an evidence-based best practice leading to better outcomes for our patients rather than signing off the patient to a nephrologist. Rahul Gupta, MD, MPH, FACP, Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV
References
1. Jones C, et al. Nephrol Dial Transplant 2006;21:2133-2143.
2. Obrador GT, Pereira BJ. Am J Kidney Dis 1998;31:398-417.
3. Tseng CL, et al. Arch Intern Med 2008;168:55-62.
4. Bradbury BD, et al. Clin J Am Soc Nephrol 2007;2:89-99.
5. Kazmi WH, et al. Nephrol Dial Transplant 2004; 19:1808-1814.
6. Morbidity and mortality of renal dialysis: An NIH Consensus Conference Statement. Consensus Development Conference Panel. Ann Intern Med 1994;121:62-70.
The comments below are in response to the article "Early Referral of the Chronic Kidney Disease Patient is Good Practice," by Rahul Gupta, MD, MPH, FACP, which appeared in the Jan. 29, 2012, issue. The comments from two of our editorial board members represent somewhat differing perspectives on the role of the primary care clinician in the management of chronic kidney disease. Obviously there is great opportunity for improvement in this area and those of us in primary care are in a unique position to optimize outcomes. Stephen Brunton, MD, EditorSubscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.