The care of patients with chronic kidney disease.

Chronic kidney disease (CKD) is a public health problem. The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (K/DOQI) has recently published K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification,1 which provides definitions, prevalence estimates, and an action plan for stages of chronic kidney disease (Table 1). End-stage renal disease (ESRD) is defined as patients treated by dialysis and kidney transplantation and corresponds approximately to the stage of kidney failure (stage 5, glomerular filtration rate [GFR] <15 mL/min/1.73 m2 or treated by dialysis). According to the United States Renal Data System, the incidence in the United States was 89,252 new patients in 1999. The prevalence of ESRD was 340,261 as of December 31, 1999,2 and the projected number by the year 2010 is over 600,000.3 Hospitalization rates for patients with ESRD are high compared to age- and risk-adjusted comparative cohorts, and the life expectancy of dialysis patients in the United States is 16% to 37% of the age-, gender-, and race-matched population. The total cost was $17.9 billion in 1999,2 and has been projected to be in excess of $28 billion by the year 2010.3 Table 1 Classification, Prevalence and Clinical Action Plan for Chronic Kidney Disease* The prevalence of earlier stages of CKD is even higher. Estimates for decreased GFR (corresponding to Stages 3 and 4) range from 0.8 to 8 million, depending on the cutoff values for serum creatinine (SCr) or estimated GFR.1,4 There may be as many as 20.3 million individuals with kidney damage, estimated by the presence of microalbuminuria or albuminuria (Stages 1 and 2).1 Therapeutic interventions implemented early in the course of CKD have been demonstrated to be effective in delaying or preventing the adverse outcomes of chronic kidney disease.5–7 The clinical action plan recommended by the NKF-K/DOQI clinical practice guideline focuses on: early detection, diagnosis, and treatment; slowing progression to kidney failure; detection and treatment of complications; preparation for and timely initiation of kidney replacement therapy; and diagnosis and treatment of cardiovascular disease and other comorbid conditions. The article by Winkelmayer et al.8 focuses on selected comorbid conditions that could be tracked through administrative data. They demonstrate a low prevalence of preventive and screening tests among patients with CKD in the year prior to and in the year after the start of renal replacement therapy. They note that screening for cancers (breast and cervical among women, and prostate among men), and preventive measures for diabetes care (eye exam and hemoglobin A1C) were well below the rates for a general managed care population in the same geographic area. Potential explanations they put forth were physician inattentiveness, fatalism about patient outcomes, poor patient adherence to testing, and inadequate financial coverage for these tests. They conclude that increased testing may result in improved health outcomes among patients with end-stage renal disease. Other reports have suggested that care of patients with CKD in the United States may be suboptimal.9 We agree with the authors' discussion of possible causes of suboptimal care in the patients they studied. We suggest that the reported lack of comprehensive health care management offered to patients with CKD may be addressed by a more effective collaboration between the patients' primary care physicians and the specialists who participate in their care, following the action plan proposed in the NKF-K/DOQI guidelines.