Monday, August 12, 2013

Ten Things Every Primary Care Physician Should Know

An article from a few years ago that might provoke some discussion. Some of the recommendations are a little out of date (I don't think I would target a Hb of 12 anymore in patients with CKD) but overall it seems like good advice.

The Top 10 Things Nephrologists Wish Every Primary Physician Knew
  1. A "normal" serum creatinine level may not be normal.
  2. Know the medications that spuriously raise the serum creatinine.
  3. Patients with decreased GFR or proteinuria should be evaluated to determine the cause; positive urine dipstick results for protein should be followed up with a spot urine protein/creatinine ratio.
  4.  In patients with early-stage CKD, periodic evaluation and intervention are appropriate to slow the progression of renal disease and avoid complications.
  5. Do not automatically discontinue an ACEi or ARB solely because of a small increase in serum creatinine or potassium.
  6. Anemia in patients with CKD should be treated with ESAs but should not be over-treated.
  7. Phosphate-containing bowel preparation should be used with caution
  8. Patients with CKD should avoid magnesium or aluminum-containing oral preparation. Concomitant use of citrate-containing preparations and aluminum-containing oral preparation is hazardous because it can lead to acute aluminum toxicity
  9. Although most patients with hypertension should not be screened for secondary hypertension, certain clinical clues may suggest the presence of an underlying cause that, when addressed, may resolve or improve the patient's hypertension
  10. In patients with recurrent stone disease, an in depth metabolic evaluation is needed to identify and treat modifiable risk factors, thereby preventing further episodes and/or promoting stone dissolution
I don't see much to disagree with on this list - I might not put the knowledge that bactrim and cimetidine increase creatinine so high on the list. I particularly like number 10 - most patients with recurrent stone disease are unaware that more than 95% of stone recurrences can be prevented with proper medical therapy.

With regard to number 8, although we don't really use aluminum-containing phosphate binders any more, it is still contained in some over-the-counter antacids. Citrate markedly increases the absorption of aluminum from the bowel and in patients with CKD, this has been associated with severe toxicity and death in one case series.

Are there any other things that we should add to this list?

5 comments:

Anonymous said...

Don't send a patient with diabetes, a creatinine of 1.4 and proteinuria of 50 mg who is already on Lisinopril for evaluation to a Nephrologist - they do not do much different and the patient gets unnecessarily concerned.

Anonymous said...

Meh, I disagree with not sending that person to nephrologist. If nothing else, it's a bit of a wake up call about the future if the patient doesn't shape up. No need for repeat visits, but a one-time visit isn't unreasonable with an arguably abnormal creatinine and clear risk factor for progression. YMMV

Leonardo V Riella, MD, PhD said...

Nice list Gearoid.

Few more that might be useful:

1. Don’t assume a patient on dialysis does not make any urine. It may be handy in cases of acute dyspnea/volume overload.
2. Patient on hemodialysis comes in with vague complaints. Assume infection or cardiovascular event until proven otherwise. Blood cultures should always be sent.
3. CCB and hydralazine are neither renally cleared or HD removed. ACEI are HD removed.
4. Avoid atenolol in patients with renal failure since it is renally cleared.
5. Avoid blood transfusions if possible due to risk of sensitization (limit future transplantation). If PRBC are necessary, order leukoreduced.

Anonymous said...

Disagree with Number 6 - not all CKD patients with 'anemia' need or should be treated with ESAs. Symptoms must be taken into account.

R. W. Donnell said...

Stay away from NSAIDs.