CKD and the interdisciplinary team: the logic behind the trend.

CKD is a term that has been coined in the last decade, one that encompasses a wide spectrum of kidney diseases that lead to persistent kidney injury. CKD is a morbid condition as cure remains elusive. In many instances, the disease is “progressive” and end-stage kidney disease (ESKD) is imminent, committing the individual to lifetime kidney replacement therapy in the form of dialysis or kidney transplantation. In other instances, the disease is “mild” with a low likelihood of progression, and yet a diagnosis of CKD may be just as grim because many studies have shown that CKD is an independent predictor of cardiovascular disease and mortality. 1-4 Current epidemiologic studies approximate the prevalence of CKD to 11% in the United States, 5 and data from other countries indicate that the increasing prevalence of CKD is shared globally. This is alarming. In addition to the individual disease burden, management of individuals with CKD places a high burden on health care systems. The cost of ESKD management was estimated to account for 6.3% of total Medicare spending in 2011. 6 Current guidelines for the management of CKD focus on strategiestoslowdiseaseprogressionandtoreducetherisk ofcardiovascularevents,treatmentofcomplicationsrelated toCKDsuchasanemiaandmineralandbonedisorder,and educationandpreparationforkidneyreplacement therapy. CKD requires dietary counseling, psychological support, and social worker services to help navigate a complicated health care system. Providers are tasked with caring for medically complex patients in an era of evolving health care systems including the introduction of electronic medicalrecordsandchangingre-imbursementrules.Inthisissue of Advances in Chronic Kidney Disease, we highlight the magnitude of the task and the utility of a multidisciplinary approach to the patient with CKD. In their article, Saxena and Rizk advocate for an interdisciplinary approach to the patient with CKD as they examine the shortcomings of the current system. They review studies that have attempted to understand the potential benefits of interdisciplinary clinics and whether this is a cost-effective avenue to pursue in the management of patients with CKD. They identify early referral and patient education as key elements to the success of such a model. The potential use of innovative information and technology tools is also explored. This is followed by an in-depth review of the value of CKD education by Davis and Zuber. Subsequently, the issue includes a timely article about health information technology, its potential benefits, and the challenges it has created for health care providers in general including kidney providers. Other articles in this issue emphasize the importance of proper access planning for dialysis, the need for contemporary nutritional counseling, and the required awareness of poly-pharmacy and medication dosing in this patient population. Some of the common primary care issues in patients with CKD are also reviewed. In considering the high rates of depression associated with a diagnosis of CKD, Schell and others outline the evaluation and management of depression in patients with CKD. All too often, we are occupied with the medical management of our patients, and we fall short of addressing their emotional needs. Although resources do exist for depression assessment and counseling of patients with ESKD on dialysis, these resources have not been routinely extended to patients with CKD before onset of dialysis. Similarly, palliative care appears to be underused in patients with CKD even when the prognosis is poor. Palliative care has been shown to improve the quality of life when it is integrated early on in the care of patients with terminal illnesses, and we need to do a better job of incorporating it into the overall care we deliver for patients with advanced CKD who have a poor prognosis. Ultimately, we are in dire need of novel therapies to slow or better, reverse, kidney disease progression and to reduce the risk of cardiovascular disease in patients with CKD. In thisissue,wededicateanarticletounderstandingtheobstacles to clinical research in patients with CKD. Decker and Kendrick provide a detailed discussion to this point highlighting system and patient barriers for clinical research in patients with CKD. Several solutions are proposed. Collectively, the contributions to this issue emphasize the complexity of managing CKD in the individual patient and as a public health problem. An interdisciplinary approach to the management of the individual patient with CKD is necessary considering the multidimensional implications of the diagnosis. Most importantly, the high prevalence of CKD calls for concerted efforts to prevent and to treat CKD. As a community, we need to assert our commitment, not only to slow CKD progression but also to reduce mortality in patients with CKD. Everyone deserves a second chance.