SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
VOLUME 7 NUMBER 1 • MARCH 2010
15
It is recommended that, after evaluation of co-morbidities
and prognosis, patients showing this rate of decline should
be referred for specialist evaluation. In my experience, GPs
merely seek reassurance that they are doing all they can to
prevent unnecessary loss of renal function, and this can often
be provided by email or letter without the need for a formal
clinic visit.
Referring patients with CKD for specialist advice
Broadly, there are two reasons for referral of patients with
CKD to a nephrologist:
To seek clarification when diagnostic uncertainty exists,
•
ie
to identify people whose renal disease exhibits features
that are not in keeping with CKD due to systemic vascular
disease and who may need specialist evaluation and
intervention.
To give patients known to have CKD timely access to
•
specialist services not available in primary care, such as
pre-dialysis work-up, anaemia management
etc
.
With regard to the first of these, it is important that GPs are
familiar with the expected clinical features of CKD and can
identify features that suggest a patient’s renal impairment
may be due to something other than systemic vascular disease
(and may possibly have a remediable cause). The following
are useful diagnostic clues:
Patients with CKD due to systemic vascular disease
•
must have a defined risk factor, such as hypertension or
diabetes, and failure to identify one raises the possibility
of primary renal disease.
Heavy proteinuria (ACR
•
>
70 mg/mmol, PCR
>
100 mg/
mmol is not typical of CKD. These patients may have a
primary renal disease.
Haematuria (seen or unseen) rarely accompanies CKD
•
caused by systemic vascular disease. This finding should
prompt referral according to local guidelines.
The decline in renal function in CKD is slow. As outlined
•
above, NICE has defined a rate of fall in eGFR above
which referral is advised. In patients whose rate of
decline is accelerated by ACE inhibitors, the possibility of
renovascular disease is raised. Patients with a low eGFR
and with these features may warrant a specialist opinion
to exclude other conditions before automatically placing
them on the CKD monitoring/management pathway.
Summing up
In summary, by detecting renal excretory impairment and
proteinuria, GPs can readily identify patients with CKD. In
doing so, they can identify patients at risk of cardiovascular
events and have an opportunity to take measures to reduce
this risk. NICE has now given guidance on testing for CKD, but
some issues are not fully resolved because the evidence base
used by the guideline committee was weak in certain areas.
More evidence is required to support the clinical and economic
basis for using ACR as the screening test of choice (and as a
quality measure in the QOF). Most importantly, we need to
establish robust data to reveal the relevance of low eGFR,
and subsequent management of CKD, in elderly subjects.
References
Go AS, Chertow GM, Fan D,
1.
et al
. Chronic kidney disease and the risk
of death, cardiovascular events, and hospitalization.
New Engl J Med
2004;
351
(13): 1296–1305.
Stevens LA, Coresh J, Feldman HI,
2.
et al
. Evaluation of the Modification
of Diet in Renal Disease Study equation in a large diverse population.
J
Am Soc Nephrol
2007;
18
(10): 2749–2757.
NICE Clinical Guideline 73: Chronic Kidney Disease: Early Identification
3.
and Management of Chronic Kidney Disease in Adults in Primary and
Secondary Care. National Institute for Health and Clinical Excellence.
September 2008.
Save these dates
DATE
PLACE
CONFERENCE
26–29 March
Cape Town
International Cardiology and Diabetes meeting
9 April
Durban
Novo meeting at SEMDSA
10–13 April
Elangeni Hotel, Durban
Society for Endocrinology, Metabolism and Diabetes of SA (SEMDSA)
16–19 April
CTICC, Cape Town
SA Renal Society and the Renal Care congress
7–9 May
Sibaya Lodge, Durban
4th SA Pain congress
5–9 June
Orlando, Florida, USA
70th American Diabetes Association (ADA)
