Handing Out Grades for Care in Chronic Kidney Disease: Nephrologists versus Non-Nephrologists

There has been a remarkable increase in the collective awareness of the impact and the extent of chronic kidney disease (CKD) in the United States in the past 5 to 10 yr. When, in the 1990s, nephrology experts were asked to speculate on the size of the CKD population, rarely did any such experts provide an estimate of >1,000,000 US citizens. These estimates were not unreasonable given that approximately 100,000 patients were entering ESRD dialysis programs per year and that the mean duration of antecedent CKD was approximately 10 yr. We are now aware that 15 to 16 million US citizens have stage 2 or 3 CKD, and another 1 million or so are in stages 4 and 5 (1,2). The high prevalence of CKD justifies effort to develop a strategy for dealing with it as a matter of public health. This gives rise to several questions:

1. What is the optimal way to leverage the expertise of nephrologists given that there are more than 2000 patients with CKD stages 2 through 5 for every practicing nephrologist in the United States?

2. At which stage of CKD should patients be referred to a nephrologist?

3. What is the level of expertise that can be expected of general internists or other primary care providers in the management of CKD?

4. What is the best way to involve allied health professionals in multidisciplinary CKD care?

5. Is there a point, before ESRD, at which the nephrologist should assume primary care of a patient with CKD?

6. Should it be the purview of CKD clinics to manage cardiovascular risk, given the high cardiovascular morbidity that is conferred by CKD?

CKD is a multisystem disease, and optimal therapy for CKD will address its many facets. Although the complexity of this may seem daunting, the individual processes are predictable …