Dr. Bakris, Dr. Agarwal, Dr. Wright, and Dr. Minkoff have recently come together to discuss how they assess kidney function and ultimately diagnose chronic kidney disease (CKD).
Assessing Disease Severity
Dr. Bakris emphasizes that measuring the glomerular filtration rate (GFR) is not sufficient to assess disease severity. It’s important to also understand albuminuria. He explains that some patients have a GFR of 70mL/min but their proteinuria is 4g, which is not a normal kidney function. Testing for both proteinuria and GFR is therefore essential to understand what stage patients are in.
Assessing what stage patients are in is essential and must be the first step. However, it’s also important to understand the cause in order to best treat patients.
Assessing Cause
Diabetes is the leading cause of kidney failure worldwide. Dr. Bakris explains that his most common referral is from patients who are diagnosed with diabetes and are also having poor control with their blood pressure, high creatinine levels, and albumin in the urine. Hypertension is the second leading cause of kidney failure.
When examining patients with both diabetes and poorly controlled hypertension combined, they account for 75% of all kidney failure patients worldwide.
Dr. Bakris emphasizes that it’s important to also understand a patient’s family history. Although this doesn’t tell you everything about the patient, it provides a good baseline. It can provide a large amount of information in a short time. Additionally, there’s no cost associated with it.
Outside of diabetes, poorly controlled hypertension, and a family history of CKD, other causes of CKD are much less common. Two of the most common of these more rare reasons include immunoglobulin A nephropathy and polycystic kidney disease. Other less common reasons include focal glomerulosclerosis, glomerulonephritides, and more.
KDIGO
In discussing proper assessment, Dr. Minkoff brought up a great question. How does a PCP incorporate the necessary testing and steps to assess severity and cause in their clinic? Dr. Bakris’ answer? Use the KDIGO as a guide.
KDIGO stands for the Kidney Disease Improving Global Outcomes heat map. It is the international guidelines developed for nephrologists. It was first created in 2001 and it is easily color-coded. There are GFR stages on the left and albuminuria staging on the top. You simply need to see which box patients fall into. If they land on a green box, there’s no need for concern. If it’s a yellow box, they should undergo further observation. If the patient is in an orange box, there is certainly cause for concern. Finally, if they are in a red box they have fully established kidney disease as well as a high cardiovascular risk.
Dr. Bakris discusses how the cardiovascular risk which comes along with CKD can’t be ignored. The worse the kidney function, the higher the CKD stage, and the higher the cardiovascular risk.
Speaking to Patients
Something that is incredibly critical to the process of patient care is that the patient understands what is going on, and what their health currently looks like. This responsibility in many ways falls to their doctors.
Dr. Bakris explains that one simple way to help patients visualize things is to show them the KDIGO chart and where they fall. The patient should know exactly where they currently stand. Dr. Bakris says that knowing this can also help to improve adherence. It will help build trust between them and their healthcare team and ensure that they feel comfortable moving forward.
Dr. Wright adds that he has personally seen the “light go off” for patients when they’re shown the chart. It’s clear, easy to understand, and can help them to know exactly what’s going on. After they know this, their most frequent follow-up question is “what can I do to move into the green zone?”
You can read more about this conversation and how to assess CKD severity here.
