Coping with chronic kidney disease.

Chronic kidney disease affects more than 20 million Americans and costs our health care system billions of dollars annually. About 8 million individuals have an estimated glomerular filtration rate less than 60 mL/min per 1.73 [m.sup.2], and of that number, 100,000 patients per year reach the stage where they need dialysis.

The challenge to nephrology is to address chronic kidney disease early and plan for the transition from stage 4 disease to stage 5 end-stage renal disease (ESRD) and dialysis. Typically, nephrologists do not see chronic kidney disease (CKD) patients until they are at stage 5, but waiting to refer patients until dialysis is finally needed is not the best approach.

Primary care physicians can help nephrologists meet this challenge. In fact, they have an essential role to play in helping CKD patients manage the heavy burden of cardiovascular disease and facilitating their transition to ESRD and dialysis. Currently, this transition is not managed well for a variety of reasons.

There appears to be little planning for the transition to ESRD in this country. We do not have a CKD education benefit in the Medicare program, nor do we have a benefit from other health plans that encourages referral, access placement, dietary management, and modality selection such as early kidney transplantation versus the different forms of dialysis.

For example, 80% of ESRD patients use a catheter as their first access to dialysis. This is dramatically different from almost every other country. In Japan, the percentages are virtually reversed, as only about 10% of ESRD patients get catheters as their first dialysis access. In other countries, catheter use is even less common. Catheter utilization contributes to the high morbidity from infections and high mortality in the first year of dialysis in the United States.

CKD among the elderly is common and is likely to increase as our population ages and the current diabetes epidemic continues. Primary care physicians can do much to monitor disease progression. They can be vigilant about prescribing ACE inhibitors and angiotensin receptor blockers for their CKD patients, as these agents have been shown to reduce cardiovascular events and slow progression of kidney disease.

Above all, they should consider referral to nephrologists early to address the high rates of cardiovascular events that occur in CKD patients and that kill many of them before they get to dialysis. Early referral will also help in the planning for early transplantation before dialysis is started in order to avoid the vascular access complications.

DR. COLLINS, professor of medicine at the University of Minnesota, Minneapolis, is president of the National Kidney Foundation.

BY ALLAN COLLINS, M.D.