Questions to Expect From CKD Patients

Although chronic kidney disease (CKD) affects an estimated 30 million US adults, most cases are likely undiagnosed.¹ When patients with CKD become aware of their condition, they often have many common concerns and questions that they will ask their physicians.

James J. Matera, DO, nephrologist and vice president of Medical Affairs at CentraState Medical Center in Freehold, New Jersey, discusses how to best address patients’ questions about their condition, and how primary care physicians and nephrologists can collaborate in order to optimize patient outcomes.

Consultant360: What are some common questions patients ask their primary care physicians about CKD?

Dr Matera: Many times, patients with CKD are not even aware that they have CKD. This often will lead to misunderstanding, frustration, and lack of preventative measures targeted at reducing or impacting the progression of CKD. Primary care physicians need to act as true experts in this regard, as patients will often have many questions that they do not feel were adequately answered. These include:

• The impact CKD may have on their lifestyle and how it will progress, which depends on their associated comorbidities, particularly diabetes and hypertension.
• Oftentimes, patients will say, “I feel fine. How can I have CKD?” They may want to know what symptoms they may experience, which can make it difficult to communicate to them that they may not experience any symptoms until the disease is fairly advanced.
• Patients will want to know what they can do to limit the impact of this condition on their kidneys. Self-care management is of paramount importance and includes adjustments in diet and lifestyle.
• Many patients will have questions about dialysis, even if it is not something that will be incorporated into their care plan in the near future. They may want to know specifically what they can do to avoid dialysis, and that would be an excellent talking point to jumpstart lifestyle modifications, diet, and adherence to medications and medication regimens.
   

C360: Could you discuss the impact of CKD on comorbid conditions and the need to limit risk, specifically cardiovascular risk?

Dr Matera: We must emphasize to our patients that cardiovascular disease (CVD) is the primary driving factor of morbidity and mortality, not kidney disease.  Most of our patients will have comorbid diabetes and/or hypertension, and control of these 2 conditions is essential for limiting progression of CKD.

There have been some great studies as of late, including the CREDENCE study, which not only focused on control of diabetes, but also what agents can be used to reduce cardiovascular risk and CKD risk. Patients will certainly have questions regarding these medications for their disease conditions.

In addition, I certainly think population health management plays a critical role in reducing CKD progression, and enrolling patients in available population health strategies or programs hospital can go a long way in achieving these goals. In my practice, we were able to start an excellent outpatient hypertension model that was recognized by the US Department of Health and Human Services’ Million Hearts program.

Consultant360: How can primary care providers best foster collaboration with nephrologists to enhance outcomes and deliver population health?

Dr Matera: I think this is an important question when it comes to our ability to control the progression of CKD. I feel very strongly that collaboration between the primary care physician and the nephrologist is a predictor for patient outcomes. Oftentimes, I tell others that when I see a stable CKD stage 3 patient, my impact on that patient's management may be very limited if their condition is managed well in the primary care setting.

One thing I do feel, however, is that once the patient is starting down the road towards end-stage renal disease, early education and input from the nephrologist is very important in choosing modalities for dialysis. I certainly would like to see much more progress made in the arena of home dialysis, including home hemodialysis and peritoneal dialysis. In fact, the recent focus of the government on these issues brings this whole area of medicine to the forefront again. I think this is great for the dialysis and CKD communities.

It is very important for the nephrologist to work collaboratively with the primary care physician so that the primary care physician can fully understand what to expect as the patient lives with CKD. This can include changes in electrolytes, such as potassium, phosphorus, and parathyroid, as well as development of acidemia and other sequelae that are often seen as CKD progresses. This can be as simple as an exchange of information and reporting, all the way up to a care plan that can be fostered between the nephrologist and the primary care physician. Again, the patient must be in the center of these conversations and must be empowered to help make decisions in this regard.

Consultant360: How can primary care physicians and nephrologists discuss and collaborate with patients on their CKD treatment plans?

Dr Matera: This is a great question. The theory is always there, but the execution is often times left up in the air. This may be because of poor communication of electronic medical records, so pure exchange of information may be limited. It may also be due to the fact that we simply get lost in our daily activities surrounding patient care, and as a result, communication is sometimes put on the backburner.

I truly feel that is my job to provide primary care physicians with a game plan of what to expect as the patient progresses through CKD. This includes early education, as I mentioned earlier, as well as disease-modifying tactics that limit comorbid conditions.

The exchange of information should be free-flowing between the nephrologist and primary care physician and, likewise, the primary care physician must keep the nephrologist abreast of any medication changes or developments that may impact the patient’s CKD. For example, hyperkalemia is often an adverse effect of many of the medications that we use to treat diabetes, hypertension, and heart failure, and oftentimes its presence will necessitate an adjustment in medications to improve this condition. I think a working collaborative agreement between the primary care physician and the nephrologist will allow these medications to be used with adjustments or additions to allow maximum benefit.

—Christina Vogt

References:

1. Chronic kidney disease basics. Chronic kidney disease initiative. Centers for Disease Control and Prevention. https://www.cdc.gov/kidneydisease/basics.html. Last updated December 6, 2018. Accessed September 19, 2019.
2. Matera JJ. What do CKD patients ask? Presented at: Cardiometabolic Risk Summit 2019; October 24-26, 2019; Orlando, FL.