Nephrology
Preface Ambulatory Nephrology
Samuel Snyder, DO, FACP, FACOI, FASN Editor
You can’t do it all in one small issue. There is a rising tide of kidney disease in the United States. The major causes continue to be diabetes and hypertension, and now, the impact of obesity magnifies the effect of these. It is difficult to ascertain the prevalence of chronic kidney disease (CKD) with precision, but we know this much. From 1973 when Medicare established the End Stage Renal Disease program, ESRD has grown from 10,000 patients to over 615,000 patients in 2012.1 Based on extrapolation from NHANES III data, using decreased eGFR as the defining criterion (stage 3 or higher CKD), the prevalence of CKD in the United States might be as high as 10.4%.2 Consideration of proteinuria improves the predictive power of eGFR for predicting risk of progression of kidney disease.3 The impact of this tide is that CKD is associated with greater risks of cardiovascular morbidity and mortality, and in fact, all cause mortality, as well as greater consumption of health care resources.4,5 Hence, there is a need for greater understanding and more aggressive investigation and treatment. The range of problems to which the kidney is heir is deep and wide. The signs and symptoms of kidney disease are final common pathways through which many insults are expressed. Often these expressions surface first in the primary care physician’s office. As the prevalence of kidney disease is increasing, its diagnosis and initial management are falling more commonly to the primary care physician. It is our goal here to update the primary care physician about several classic presentations and to present a sample of the some current problems in nephrology as they impact primary care. Classic problems include proteinuria, hematuria, and renal cysts. We present contemporary perspectives on these problems to streamline the diagnostic approach according to current understanding. The most prevalent disease in the United States is hypertension. The percentage of hypertension that is secondary rather than essential is considered to be increasing. We present a review of secondary hypertension, covering the appropriate indices of suspicion, and workup. In addition, we present a state-of-the-art review on the use of
Prim Care Clin Office Pract 41 (2014) xiii–xiv http://dx.doi.org/10.1016/j.pop.2014.09.002 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
xiv
Preface
angiotensin-converting-enzyme inhibitors and receptor blockers in the use of hypertension, heart disease, and kidney disease. Acute kidney injury is presented in two aspects. One of the most widely prescribed drug classes—and widely used over the counter—is nonsteroidal anti-inflammatory drugs, including COX2s. We present a current review of this subject, which remains timely despite our long experience with this serious and common problem. The single article in this collection that is not based mostly in outpatient medicine is the article on nosocomial acute kidney injury. However, the focus is still on primary care, and the emphasis is on prevention of this complication of modern medicine. Because of the increasing prevalence of chronic kidney disease, its management is increasingly a problem in which the primary care physician and the nephrologist must act cooperatively on behalf of our patients. We present several aspects of the spectrum of CKD, including a perspective on how the partnership between nephrologist and primary care physician might look as the patient progresses through the stages of CKD. As our population ages, the prevalence of CKD in the geriatric population increases, and the special needs of this growing subset are considered. Of course, the optimal treatment for end-stage CKD is transplant, and the kidney transplant patient presents more frequently than ever before to the office of his primary care physician, so this is a group that requires special consideration as well. This issue also presents a state-of-the-art review of the fastest-growing epidemic in America: the epidemic of obesity. In order to increase awareness of this problem, this article discusses how the epidemic of obesity targets the kidney as well as the heart and is a growing cause of CKD. It is impossible to be comprehensive about the practice of ambulatory nephrology in any single issue. But it is our hope to present a useful collection of the more common challenges in nephrology with which the primary care physician must be familiar and to stimulate your interest in further reading. Samuel Snyder, DO, FACP, FACOI, FASN Nova Southeastern University College of Osteopathic Medicine Fort Lauderdale, FL, USA Osteopathic Internal Medicine Residency Mt. Sinai Medical Center Miami Beach, FL, USA E-mail address: [email protected] REFERENCES
1. United States Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End Stage Renal Disease in the United States. Bethesda (MD): National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013. 2. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA 2007;298:2038–47. 3. Hallan SI, Ritz E, Lydersen S, et al. Combining GFR and albuminuria to classify CKD improves prediction of ESRD. J Am Soc Nephrol 2009;20:1069–77. 4. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events and hospitalization. N Engl J Med 2004;351:1296–305. 5. Khan SS, Kasmi WH, Abichandani R, et al. Health care utilization among patients with chronic kidney disease. Kidney Int 2002;62:229–36.
Preface Ambulatory Nephrology
Samuel Snyder, DO, FACP, FACOI, FASN Editor
You can’t do it all in one small issue. There is a rising tide of kidney disease in the United States. The major causes continue to be diabetes and hypertension, and now, the impact of obesity magnifies the effect of these. It is difficult to ascertain the prevalence of chronic kidney disease (CKD) with precision, but we know this much. From 1973 when Medicare established the End Stage Renal Disease program, ESRD has grown from 10,000 patients to over 615,000 patients in 2012.1 Based on extrapolation from NHANES III data, using decreased eGFR as the defining criterion (stage 3 or higher CKD), the prevalence of CKD in the United States might be as high as 10.4%.2 Consideration of proteinuria improves the predictive power of eGFR for predicting risk of progression of kidney disease.3 The impact of this tide is that CKD is associated with greater risks of cardiovascular morbidity and mortality, and in fact, all cause mortality, as well as greater consumption of health care resources.4,5 Hence, there is a need for greater understanding and more aggressive investigation and treatment. The range of problems to which the kidney is heir is deep and wide. The signs and symptoms of kidney disease are final common pathways through which many insults are expressed. Often these expressions surface first in the primary care physician’s office. As the prevalence of kidney disease is increasing, its diagnosis and initial management are falling more commonly to the primary care physician. It is our goal here to update the primary care physician about several classic presentations and to present a sample of the some current problems in nephrology as they impact primary care. Classic problems include proteinuria, hematuria, and renal cysts. We present contemporary perspectives on these problems to streamline the diagnostic approach according to current understanding. The most prevalent disease in the United States is hypertension. The percentage of hypertension that is secondary rather than essential is considered to be increasing. We present a review of secondary hypertension, covering the appropriate indices of suspicion, and workup. In addition, we present a state-of-the-art review on the use of
Prim Care Clin Office Pract 41 (2014) xiii–xiv http://dx.doi.org/10.1016/j.pop.2014.09.002 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
xiv
Preface
angiotensin-converting-enzyme inhibitors and receptor blockers in the use of hypertension, heart disease, and kidney disease. Acute kidney injury is presented in two aspects. One of the most widely prescribed drug classes—and widely used over the counter—is nonsteroidal anti-inflammatory drugs, including COX2s. We present a current review of this subject, which remains timely despite our long experience with this serious and common problem. The single article in this collection that is not based mostly in outpatient medicine is the article on nosocomial acute kidney injury. However, the focus is still on primary care, and the emphasis is on prevention of this complication of modern medicine. Because of the increasing prevalence of chronic kidney disease, its management is increasingly a problem in which the primary care physician and the nephrologist must act cooperatively on behalf of our patients. We present several aspects of the spectrum of CKD, including a perspective on how the partnership between nephrologist and primary care physician might look as the patient progresses through the stages of CKD. As our population ages, the prevalence of CKD in the geriatric population increases, and the special needs of this growing subset are considered. Of course, the optimal treatment for end-stage CKD is transplant, and the kidney transplant patient presents more frequently than ever before to the office of his primary care physician, so this is a group that requires special consideration as well. This issue also presents a state-of-the-art review of the fastest-growing epidemic in America: the epidemic of obesity. In order to increase awareness of this problem, this article discusses how the epidemic of obesity targets the kidney as well as the heart and is a growing cause of CKD. It is impossible to be comprehensive about the practice of ambulatory nephrology in any single issue. But it is our hope to present a useful collection of the more common challenges in nephrology with which the primary care physician must be familiar and to stimulate your interest in further reading. Samuel Snyder, DO, FACP, FACOI, FASN Nova Southeastern University College of Osteopathic Medicine Fort Lauderdale, FL, USA Osteopathic Internal Medicine Residency Mt. Sinai Medical Center Miami Beach, FL, USA E-mail address: [email protected] REFERENCES
1. United States Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End Stage Renal Disease in the United States. Bethesda (MD): National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013. 2. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA 2007;298:2038–47. 3. Hallan SI, Ritz E, Lydersen S, et al. Combining GFR and albuminuria to classify CKD improves prediction of ESRD. J Am Soc Nephrol 2009;20:1069–77. 4. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease and the risks of death, cardiovascular events and hospitalization. N Engl J Med 2004;351:1296–305. 5. Khan SS, Kasmi WH, Abichandani R, et al. Health care utilization among patients with chronic kidney disease. Kidney Int 2002;62:229–36.
