What's the Primary Care NP's Role in Managing CKD Patients?

Some of the nurse practitioners participating in Midlevels for the Medically Underserved recently let me know that they see a lot of patients with chronic kidney disease (CKD). Whether these patients are presenting for management of CKD itself or another issue, management and treatment of patients with such chronic comorbidities can be complex. Prescribing, for example, reaches a new level of complexity as the NP must decide which medications and at what doses and intervals are appropriate for the CKD patient. 

So, as part of MMU's curriculum, we are diving in to the topic of chronic kidney disease in the upcoming weeks with some practical tips for managing this patient population. As I was thinking more about this subject, defining the role of primary care in CKD seemed like a natural place to start. 

The role that primary care nurse practitioners play in managing chronic kidney disease depends somewhat on level of experience and comfort. New NPs, for example, may refer these patients to nephrology more quickly, or play less of a role in management. So, make sure that your patient care is up to par by considering your own level of expertise and that of other providers in your practice. The following guidelines give a general overview of what you as an NP should expect to be responsible for when it comes to CKD patients in the primary care setting. 

What's involved with diagnosis and management of CKD?

There are a number of considerations for any provider when it comes to diagnosis and management of patients with chronic kidney disease. To give a general overview, the following items must be taken into consideration either by the PCP or nephrologist: 

  • Screening
  • Diagnosis (including evaluation of cause) 
  • Treatment based on diagnostic specifics
  • Management of comorbid medical conditions (ex. HTN, diabetes) 
  • Implementation of measures to slow the loss of kidney function
  • Prevention and treatment of complications (ex. decreased kidney function, cardiovascular disease) 
  • Preparation for and implementation of kidney replacement therapy by dialysis or transplantation
  • Advanced care or end-of-life planning

As a primary care nurse practitioner, many of these considerations will fall within one's role and scope of practice. 

How does primary care become involved?

There are a number of ways primary care providers become involved with CKD patients. A patient under the PCP's care may, for example, have known kidney disease. Chronic kidney disease is usually asymptomatic in early stages so in many cases reduced kidney function is an incidental finding on routine labs. Or, the PCP may discover proteinuria or hematuria on a routine urinalysis leading to further evaluation and a diagnosis of CKD. This is especially true in high risk patient populations such as in individuals with diabetes.  

When is referral to nephrology indicated?

Early referral to nephrology is extremely important in CKD. All patients with a GFR of less than 30 should be promptly referred for specialty care. In addition, the American Academy of Family Physicians recommends referral to nephrology with any of the following findings in CKD patients:

  • Acute, complex, or severe cardiovascular disease
  • Anemia of CKD
  • Bone or mineral disorder of CKD
  • Difficult to manage or adverse effects of medications
  • Hyperkalemia (>5.5) despite treatment
  • Refractory proteinuria
  • Resistant hypertension (target pressure not achieved with at leat 3 antihypertensive medications)
  • Unexplained decrease in GFR of greater than 30 percent over four months

It is essential that NPs working in primary care routinely assess for these complications/indications so that the patient is appropriately referred for specialty care. 

What complications and comorbidities should primary care providers look for/manage?

Common complications of CKD include (but are not limited to): anemia, hyperkalemia, salt/water handling abnormalities, metabolic acidosis, bone disease and manifestations of a uremic state such as CNS effects. Nurse practitioners must be aware of the common complications associated with CKD and assess for these regularly in their patients. 

In addition, patients with CKD have or are prone to developing an array of comorbidities, particularly cardiovascular disease. NPs in the primary care setting must focus on prevention, screening for and management of comorbid conditions. For example, CKD patients should be screened for smoking status and provided smoking cessation support if necessary as well as have routine monitoring of lipid levels. Death from cardiac disease is more likely than progression to end-stage renal failure in CKD patients making this component of treatment important. 

How are roles and responsibilities divided for dialysis patients?

In dialysis patients, the division of responsibilities between the nephrologist and primary care provider often becomes muddied. Ultimately, studies show that although nephrologists are heavily involved in the dialysis patients' care, primary care services are still essential as these providers are more familiar with certain screening and management guidelines for comorbid conditions. In general, the ideal breakdown of responsibilities should look like: 

  • Nephrology: dialysis support, managing hypovolemia/hypertension, treatment of anemia with erythropoietin, control of renal disease, vaccinations, TB testing, vascular access for dialysis, social work support
  • Primary Care: management of diabetic care, dermatologic care, dental care, GI care, bone abnormalities, psychiatric services or referral (ex. depression screening), sleep disorders, neurologic disorders, advance care planning

Overall, primary care nurse practitioners play a significant role in the management and treatment of patients with chronic kidney disease and must familiarize themselves with screening, diagnostic, management and treatment guidelines. 

Resources: 

  1. UpToDate - Overview and management of chronic kidney disease in adults
  2. Medscape - Chronic kidney disease
  3. AAFP - Chronic kidney disease: detection and evaluation

 

Comments

I've been a nephrology APN for 11.5 years. While this article is a great start, please be aware that many nephrology practices practice primary care for their CKD and ESRD pt population due to their complexity. My caveat to ALL providers who care for nephrology pts is to remember renal dosing. If you have questions, call the nephrology provider. We also make a huge point to our pts NOT to fill ANY Rx without contacting us to ensure it is an appropriate med and dose.

Judi Dansizen, APN

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