MANAGING CHRONIC RENAL INSUFFICIENCY
Application of evidence-based management of progressive renal insufficiency prior to onset of end-stage renal disease (ESRD) affords a reasonable probability of decreasing mortality and morbidity while delaying ESRD. This review provides strategies that may prolong the interval between discovery of kidney disease and ESRD, and also may improve patient outcomes in chronic renal insufficiency.
RELATIVE ROLES OF THE NON-NEPHROLOGIST AND NEPHROLOGIST
Collaboration between nephrologist and generalist is crucial during the course of declining renal function as the condition of patients at initiation of uremia therapy may predict their subsequent clinical course and survival. The generalist serving as a primary care physician bears a central role in management of chronic renal failure (Table 1). This may be particularly fateful when there is no regional nephrologist available for expert guidance.
Diabetes mellitus and hypertension are the first and second leading causes of renal insufficiency in the US—both disorders are detected and managed by non-nephrologists for years before irreversible renal failure supervenes. By serving as “gate keeper,” generalists assume responsibility for deciding when to seek nephrologic consultation, which, if postponed inordinately may redound adversely to the patient’s long-term outcome. Thus, a primary role of the nonnephrologist is recognition and detection of chronic renal insufficiency and obtaining a nephrologic consultation. Current practice is that patients maintain their primary care physician and continue to see a nephrologist intermittently. In early renal insufficiency, the frequency of patient visits to the nephrologist (every two weeks to every eight weeks) depends on the severity of coexistent problems such as hypertension or anemia. As renal failure progresses, frequency of follow-up visits should increase since coexistent problems are likely to worsen and preparations for renal replacement therapy become necessary.
Whether the nephrologist assumes primary care of the patient as renal failure progresses should be determined on a case by case basis—this decision would be influenced by patients’ coexistent illnesses since a primary care physician may still need to coordinate all specialty care. Advocating that nephrologists should assume primary care in all cases may result in nonnephrolo-gists deciding not to refer their patients.
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