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The Impact of Regular Check-ins on Kidney Disease Management

Aug 10, 2023

Chronic kidney disease is one of the leading causes of fatalities in the U.S., with an estimated 37 million adults having a diagnosis. CKD has varying stages of kidney damage that generally gets worse with time if left untreated or not appropriately treated. However, not all CKD patients will progress to end-stage kidney disease (ESKD).

Once detected, patients will need to undergo regular testing through their healthcare provider to monitor disease progression, if other health problems have developed, or if the treatment plan is working effectively. In this article, we discuss the principle of kidney disease management, the type of tests patients may require, and the role regular check-ins play in effectively managing this disease.

Key Points

  • It is possible to prevent CKD and its associated complications through early diagnosis, managing risk factors, and treating the disease.
  • Routine check-ins play an essential role in understanding a patient’s disease progression and how they respond to their treatment plan.
  • Kidney disease is a complex and progressive disorder that requires a multifaceted care team to effectively treat and manage.

Why Is Kidney Disease So Complex to Manage?

Kidney disease is complex to manage due to its progressive nature and its associated health problems. 40% of people with severely reduced kidney function are unaware that they have kidney disease. Kidney disease is categorized into five stages, with each referring to how much damage there is to the kidneys. Stage 4 is the last stage before kidney failure and is characterized by severe kidney damage, where the kidneys are close to not working at all.

The first challenge to disease management is that kidney disease care is complex and involves specialist nephrology care, primary care, palliative care, dialysis, and transplantation. Historically patient transitions across the CKD care continuum are often fragmented.

The second challenge to managing kidney disease is the frequent presence of two or more chronic conditions. For example, many kidney disease patients also have heart disease or diabetes, thus needing healthcare from multiple specialists.

Other health problems caused by kidney disease include:

  • Gout
  • Anemia
  • Secondary hyperparathyroidism (SHPT)
  • Bone disease
  • High potassium
  • Metabolic acidosis

Key Principles of Kidney Disease Management 

Since kidney disease is progressive and irreversible, early detection and treatment are essential in preserving kidney function and stopping or delaying progression. Treatment for CKD typically consists of measures to help control or manage complications and symptoms.

Screening for Chronic Kidney Disease 

The public health burden of CKD is very high, with its causes being classed as primary kidney diseases and kidney damage caused by secondary medical conditions such as diabetes and high blood pressure. As most CKD patients are asymptomatic in the early stages of the disease, screening may be an essential tool in early detection.

The National Kidney Foundation has developed a kidney profile test that includes both urine ACR and serum creatinine for estimating eGFR. Screening should be considered for those older than 60 years or those that have a history of diabetes or hypertension. Screening should also be considered for people with clinical risk factors.

Managing Risk Factors for Kidney Disease

People with high blood pressure or diabetes that successfully manage their conditions are at a lower risk than those people who do not. Thus, it is important that kidney disease patients with comorbidities are detected early so that appropriate treatment can start.

Patients with kidney disease are encouraged through lifestyle changes to manage their blood pressure, cholesterol levels, and blood sugar levels to reduce the risk of developing heart disease and stroke.

For patients with diabetes, it is crucial to monitor for kidney disease as this may prevent or delay kidney failure or cardiovascular death.

What Tests are Done to Check Kidney Function? 

All patients with kidney disease at any stage should undergo regular assessments of their kidney function. Kidney function is determined by estimating the glomerular filtration rate (eGFR) from the serum creatinine. eGFR determines the extent of kidney damage, monitors disease progression, and monitors how well the patient responds to treatment.

Once a person is diagnosed with CKD, the KDGIO guidelines recommend that low-stage kidney disease patients check in at least once a year to check their eGRF and albuminuria levels. Patients at high risk should check in for tests at least twice a year, with very high-risk patients being recommended to check in at least three times per year.

Tests used to check kidney function include:

  • Estimated glomerular filtration rate (eGFR). eGFR is considered one of the most reliable tests for clinicians to establish how well the kidneys function. eGFR measures how well the kidneys function based on a blood test, race, sex, age, and body type.
  • Urine test. Clinicians examine urine to check for signs of kidney disease, as protein may leak into the urine when there is kidney damage. Urine tests are also used to check for complications from CKD, such as anemia, metabolic acidosis, or urinary tract infections (UTIs).
  • Serum creatinine test. This blood test measures the amount of creatinine (a waste product) in the blood. When kidney function is declining, the serum creatinine levels go up.
  • Blood urea nitrogen (BUN) test. The BUN level is based on a blood test measuring urea nitrogen in the bloodstream. When the kidneys are damaged, urea nitrogen is not removed from the bloodstream. Thus, the BUN levels increase.
  • Kidney ultrasound. A kidney ultrasound is a safe and painless imaging procedure that provides a picture of the kidneys. A kidney ultrasound can be used to show something abnormal in the kidneys, signs of damage, kidney stones, and blood flow to the kidneys and the bladder.
  • Kidney biopsy. A kidney biopsy can help clinicians understand how severe the kidney damage is and what is causing the damage. A kidney biopsy may be recommended if there is blood or protein in the urine, nephrotic syndrome, or if there is kidney disease with no apparent cause.

Aside from the standard routine medical screening that most adults undergo, when you have kidney disease, you must have tests and exams done monthly, annually, or as directed by your nephrologist.

The Role of a Care Coordination Team in CKD Management 

Patients with advanced-stage CKD and ESRD need to receive care from multiple healthcare professionals across many clinical settings. This may cause fragmentation and cause gaps that patients and populations fall through.

To deliver the right care at the right time, patients need coordinated care across healthcare professionals and organizations.

Who is part of a care coordination team:

  • Primary care provider
  • A registered dietician
  • Nephrologist
  • Nurse
  • Diabetes educator
  • Pharmacist
  • Social worker
  • The transplant team
  • The patient
  • Financial Counselor/Billing personnel
  • Patient Care Technician and Renal Technologist

Panoramic Health 

Panoramic Health is a physician-led value-based care platform. We serve our patients using 14 years of experience managing outcomes using the largest and live CKD database, care management tools, and predictive analytics.

We provide our patients with a 360⁰ view of their health through our holistic CKD care coordination. Part of our holistic CKD care coordination model is our care coordination team called “Circle of Care.” The Circle of Care ensures that patients get the right treatment at the right time, improving their quality of life and disease outcomes.