The Advancement of Clinical Practice in Chronic Kidney Disease

RPA Satellite Symposium. March 22, 2002

Concluding Remarks and Program Evaluation

Anton C. Schoolwerth, M.D., M.S.H.A.

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The post-test and evaluation form are at this link, but you must listen to all talks from this symposium prior to completing the test.
CME: The Oxford Institute for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (AACME) to provide continuing medical education for physicians.
The Oxford Institute for Continuing Education designates this educational activity for up to 2 hours in category 1 credit towards the AMA Physician's Recognition Award. Each physician should claim only those hours of credit actually spent in the educational activity.

CEU: These talks are also designated to provide 2 hours of CEU nursing education credits, sponsored by the Renal Education Association. The Renal Education Association is accredited by the State of California Board of Nursing to provide continuing education for nurses (provider number: CEP 13092).

Posting date: July 3, 2002
Review date: July 3, 2003
After participating in this activity, participants should be able to:
Discuss the increased prevalence of chronic kidney disease in the United States;
Define chronic kidney disease using the stratification guidelines of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI);
Describe the need for earlier identification of and interventions for chronic kidney disease in the United States,
Describe the burden of chronic kidney disease in patients with cardiovascular complications: and
Discuss how anemia is managed in patients with chronic kidney disease and cardiovascular disease.

Schoolwerth: receives grant and/or research support from, is a consultant for, and is a member of the Speakers Bureau for Ortho Biotech Products, L.P.

Generic/Common name: Recombinant human erythropoietin (r-HuEPO; epoetin alfa).
Trade name: Procrit® or Epogen®
Approved use: Treatment of anemia in chronic renal failure; in zidovudine-treated HIV-infected patients; and in cancer patients on chemotherapy. Reduction of allogeneic blood transfusion in surgery patients
Unapproved/investigational use: Anemia in patients with congestive heart failure and the chronically critically ill.
The CME policy statements of The Oxford Institute for Continuing Education, which is the accrediting organization for this talk, are given in detail on the Symposium Home Page. CME policy and disclosure statements of HDCN are listed on this page.


Dr. Anton Schoolwerth:
We heard this evening quite a bit about chronic kidney disease. We heard that it's very common, that it's prevalent in the population, and yet its identification and recognition may be significantly lower than we were led to believe. There are a number of patients out there. We've talked about bit about the fact that this will take, then, a major educational process and it's going to take both public and professional education. But more importantly if these statistics that we're extrapolating from NHANES are anywhere near the truth ... and we believe they are ... it's going to take a concerted team effort by more than just nephrologists. There aren't enough nephrologists in the world probably, certainly not in the United States, to deal with 20 million patients if we need to become involved in all of them.


Team approach: Role of primary care physician (PCP) and nephrologist in CKD
And so part of the process and part of our challenge will be to engage our primary care providers and their teams in identifying patients and screening these patients, particularly those patients at increased risk for CKD. And those are really the ones that need to be screened. I think there's evidence that we don't need to screen the whole population. But if we go after the high risk people I think we're likely to be successful. The key data that Dr. McClellan alluded to has shown this, I think, amply.

And the overall key data that I'm aware of for the first 1,000 individuals screened nationwide showed (I don't have the breakdown for serum creatinine) really phenomenal yield, that of the six factors screened over 87 percent of the attendees had one or more abnormalities. This looks like it's going to be a high yield program and if we can extrapolate key primary care providers' offices, I think these patients are going to be identified. The primary care providers will provide ongoing management of these patients and they'll play a significant role in their education, but we, the nephrologists, have a unique opportunity. First of all, to help diagnose patients and assess them, and then to provide what I think is perhaps the most important, to develop a strategic guidance plan for the primary care providers and patients to follow. We can recommend and implement the patient care and we can also assist in education.


Source: Eknoyan G, et al. Postgrad Med. 2001 Sep;110(3):23-9: quiz 8.

Continuum of CKD care: Interaction of PCP and nephrologist
The question that's often asked by primary care providers that I've spoken to is: "At what point should we refer patients to nephrologists?" And I don't think there's a specific answer to this. But this slide attempts to deal with this. This comes from the Postgraduate Medicine article from last year, the first of a series of six articles dealing with CKD care, that indicates that there is this continuum of care involving both the primary care providers and the nephrologists and that at least by stage three, in some cases earlier than that, it's important that we both become involved.

That represents the primary care provider referring a patient to the nephrologist to assist in management of that patient, providing guidance and a variety of comorbidities that we did not discuss this evening, but of course would include anemia management, blood pressure control, addressing the level of proteinuria, bone disease, acidosis and nutrition. So I think we have a challenge ahead of us. As has also been indicated tonight much of what we are doing now is based on our belief that it's likely to be efficacious.

We have some data to support blood pressure control, decrease in proteinuria. But we really desperately need more outcomes data and I think the CHOIR study is going to be a major study to help us in terms of the role of anemia management in chronic kidney disease. There's plenty of opportunities for our collaboration and I think this is a challenge for us in the future.

I'd like to stop here at this point and thank all the panelists for their contribution. Thank you again and good evening.


1. Eknoyan G, Levey AS, Levin NW, Keane WF. The national epidemic of chronic kidney disease. What we know and what we can do. Postgrad Med. 2001 Sep;110(3):23-9: quiz 8.

This educational activity is supported by an educational grant from Ortho Biotech Products, L.P.
This activity has been planned and produced in accordance with the ACCME Essential Areas and Policies and with CE policies of the State of California Board of Registered Nursing.
From a CME Symposium held on March 22, 2002 at the Renal Physicians Association (RPA) Annual Meeting in Washington, DC. This symposium was approved by the RPA. It was not part of the official RPA Annual Meeting as planned by the RPA Program Committee.