Saturday, August 13, 2011

Care for Chronic Kidney Disease; Things to Know

 I got mad this week when I saw yet another patient not getting the best care for her kidney disease.
She had been seeing a kidney specialist. The fancy name for kidney specialist is nephrologist.

Nephrologists don't do surgery on the kidney.
Those specialists are urologists.

But nephrologists specialize in kidney disease. So they should be experts on kidney disease. 
That means that they should provide top-notch care for chronic kidney disease called CKD. Right?

Well that’s not what my patient was getting.
She had CKD from diabetes and high blood pressure.

Somehow she got to this nephrologist. I didn't send her.

Not all car shops or car mechanics are the same and that goes for nephrologists too.

There are good guidelines on management of CKD available from the National Kidney Foundation. This nephrologist always seems to ignore those guidelines or not know them. And talking to him has not helped matters.

My patient was not on a drug that has been proven to prevent worsening of her CKD.
Her kidneys were failing.
And medication, that has been proven to help, had not been prescribed.
And this wasn’t because of cost. These helpful drugs are cheap now.

Her CKD is expected to get worse. Then she will need dialysis to take the place of her failed kidneys.

Sure there are many clinical guidelines for doctors to help provide the best care based upon the best evidence. Some guidelines are not too good.

But these guidelines from the National Kidney Foundation are really solid.
They are based upon many well done clinical studies

So it really irked me to see this patient not getting good care. In this case, I went ahead and prescribed the medication. It will also help take care of her high blood pressure.

If you have CKD from diabetes, you should be on a medication that works on the renin angiotensin aldosterone system. The main medications in this category are:
·      angiotensin converting enzyme inhibitors, abbreviated ACE inhibitors
·      angiotensin receptor blockers, abbreviated ARBs.

The ACE inhibitors are generic and cheap. At this point, one ARB, is generic. It’s called losartan. 
It is generally best to use high doses of these medications to get the most benefit for the kidneys. Many doctors prescribe wimpy doses. But a low dose is much better than no dose.

If you are below the age of 80, your blood pressure goal should be below 140 systolic. 
Systolic is the upper number. ACE inhibitors or ARBs are good medicines to use because of their many benefits.

But ACE inhibitors and ARBs are not very powerful at lowering blood pressure.
And many patients will need 3 or more drugs to get their blood pressure to goal. Getting the blood pressure to goal is important to protect your kidneys from further damage.

Get another opinion if you have questions about your kidney disease. 
Just because your doctor has a busy waiting room doesn't mean he’s worth going to. 
For many people it's easier to tell with your car mechanic.


  1. Very interesting and thank you for the information. You mentioned that guidelines are based on clinical studies. Where are these clinical trials done?

  2. These particular trials were multi-center trials, most often in the US but other countries too.If you click on the guidelines you will see references at the bottom with all the key studies found in the references.
    Thanks for the comment.