Managing Diabetic Kidney Disease: What to Know Before you Refer

Many physicians-in fact, I would say the majority of physicians-do not talk to their patients about kidney disease. And, I will say that I’m a referral center, so the patients that I actually get have no idea where they’re coming to see me, and when I tell them that they have kidney disease they’re shocked.

The key elements for identifying kidney disease and treating it early in a patient are very simple. In fact, medical students can do it. So you have to be able to understand labs, including electrolytes and kidney function, and how to interpret them. That’s pretty basic. Then you have to have some knowledge about blood pressure goals, how to manage blood pressure in kidney patients, and then some knowledge about diabetes, of course, because that’s the number one cause of kidney disease.

And basically put together what you already know to treat blood pressure, glucose, and lipids. That’s pretty much all that’s required in early stage kidney disease to actually preserve kidney function.

The perspective of the new blood pressure guidelines, with regard to the patient with diabetes and kidney disease-I mean really the ADA and the AHA guidelines are 85 to 90% congruent. I mean, they really are on the same page. The message is the same: You want to have the blood pressure level certainly below 140 and, ideally, below 130. The ADA has a little bit of a difference, they’re talking about less than 140 in everybody and less than 130 in those people with a greater than 10-year 10% risk. It’s important to have continuity of care when a generalist refers to a specialist.

So awareness of chronic kidney disease is low and, in fact, primary care physicians play a critical role in CKD awareness.

The information that’s critical is, how long has a patient had this disease, so diabetes for X number of years, hypertension for X number of years. Those are important pieces of information and then, in addition to that, what has been tried and what has been successful. If there’s been a problem with medications, what problems are there: side effects, tolerability issues, and especially things like angioedema from ACE inhibitors or severe reflux from calcium blockers, those kinds of things.

Really the specialist is not having some magic wand or anything that they have a next bag of tricks that you don’t know about or anything. What they’re gonna do is really fine-tune what you should already be doing. So what should you be doing? Again we’re back to the Holy Trinity- blood pressure, glucose, and lipids. If you do those three things effectively, you’ll be very effective in slowing progression of kidney disease.

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