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Caring for Patients With Chronic Kidney Disease: A Joint Opinion of the Ambulatory Care and the Nephrology Practice and Research Networks of the Ameri

Abstract and Introduction
Abstract

An increasing number of patients are developing chronic kidney disease (CKD). Appropriate care for patients with CKD must occur in the earliest stages, preferably before CKD progresses to more severe stages. Therefore, recognition and treatment of CKD and its associated complications must occur in primary care settings. Patients with CKD often have comorbid conditions such as diabetes mellitus, hypertension, and dyslipidemia, creating specific considerations when treating these diseases. Also, these patients have CKD-related conditions, including anemia and renal osteodystrophy, that are not traditionally evaluated and monitored by the primary care practitioner. Collectively, many opportunities exist for pharmacists who practice in the primary care setting to improve the care of patients with CKD.
Introduction

Chronic kidney disease (CKD) is a health problem reaching epidemic proportions and encompasses a substantial segment of the adult ambulatory population. Although specific prevalence rates are difficult to calculate, an estimated 20 million people have CKD.[1] More specific data are available for the subset of patients with end-stage renal disease (ESRD), or renal failure, where the incidence reached almost 100,000 patients in 2000.[2] This number has doubled during the past 10 years and is expected to increase with the aging population. By 2010, the incidence of ESRD is projected to increase to more than 172,000 cases annually.[2] Similarly, the prevalence of ESRD was 372,000 cases in 2000 but is estimated to exceed 661,000 by 2010.[2] The cost of treating patients with ESRD consumes almost 6% of the total Medicare budget, accounting for approximately $19 billion annually. Although these are staggering numbers, they account for only the 2% of patients in the final stage of CKD. Millions of patients with less severe CKD represent a much broader portion of the adult ambulatory population. Therefore, the recognition and treatment of early CKD should be emphasized as a component of primary care.

The presence of CKD doubles the risk of mortality in affected individuals.[2] Meanwhile, progression to ESRD incurs a very poor prognosis, with patients having a 4 times greater rate of hospitalizations and a life expectancy that is one quarter to one fifth less than that of the general population. By far, the most common cause of death (48%) among patients with ESRD is cardiovascular disease.[3] Thus, an opportunity for improving care of patients with CKD exists through treatment of cardiovascular risk factors during earlier stages of the disease in primary care. Current treatment recommendations stress the importance of therapies that improve the morbidity and mortality of these patients, as well as therapies that prevent or delay the progression of kidney disease.[4] Most of these therapeutic interventions target the adult, ambulatory patient population in primary care. Pharmacists in a wide variety of primary care practice settings are well suited to implement and monitor therapeutic interventions to improve the care of patients with CKD.