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Renal disease is commonly encountered by primary care physicians during their day-to-day visits with patients. Common renal disorders include hypertension, proteinuria, kidney stones, and chronic kidney disease. Despite their prevalence, many physicians may be unfamiliar with the diagnosis and initial treatment of these common renal disorders. Early recognition and intervention are important in slowing the progression of chronic kidney disease and preventing its complications. The evidence-based pearls in this article will help primary care physicians avoid common pitfalls in the recognition and treatment of such disorders and guide their decision to refer their patients to a specialist.
ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blocker; BUN = blood urea nitrogen; CKD = chronic kidney disease; GFR = glomerular filtration rate; LDL-C = low-density lipoprotein cholesterol; NSAID = nonsteroidal anti-inflammatory drug
Chronic kidney disease (CKD) is a widespread public health problem with substantial morbidity and mortality. Outcomes associated with CKD are progression to kidney failure, cardiovascular disease, and premature death. Learning to recognize CKD in its earliest stage and understanding what measures to undertake to prevent its progression and associated complications are important goals developed by the Kidney Disease: Improving Global Outcomes (KDIGO) initiative.1 The evaluation of difficult-to-treat hypertension and kidney stones are additional skills that primary care physicians will need to acquire. The evidence-based pearls in this article will help primary care physicians understand these concepts and avoid common pitfalls in the recognition and treatment of such disorders and guide their decision to refer their patients to a specialist.
Every new medication (prescribed, over-the-counter, and herbal) that is given to a patient with a renal allograft should be reviewed to determine if it will interact with his or her transplant medications (eg, tacrolimus or cyclosporine). Some medications may decrease calcineurin inhibitor levels; others may cause cyclosporine or tacrolimus toxicity.43 In both instances, the health of the patient or the success of the renal allograft may be jeopardized. For example, St Johns Wort, a herbal preparation, may decrease cyclosporine levels substantially, potentially resulting in acute rejection. Several other commonly prescribed medications that can be associated with reduced cyclosporine levels include rifampin, phenytoin, and carbamazepine. In contrast, diltiazem, verapamil, and erythromycin may increase cyclosporine levels. Cyclosporine can interfere with the metabolism of certain statins such as simvastatin, increasing the risk of statin-induced rhabdomyolysis. If any medication must be given to a patient with a renal allograft who is taking tacrolimus or cyclosporine, a careful review of its interaction with these medications should be made. If a drug must be used that has a considerable interaction, dose adjustment may be needed with careful follow-up of the calcineurin inhibitor levels. Careful monitoring is the rule.
Renal disease is commonly encountered by primary care physicians. Early recognition, evaluation, and appropriate treatment and/or referral are necessary to moderate the substantial morbidity and mortality that are often associated with diseases of the kidney.
After reviewing this article, the reader should be able to (1) interpret the clinical relevance of the serum creatinine level in the setting of age, sex, muscle mass, and medications the patient is taking; (2) identify chronic kidney disease in its earliest stage and apply measures to prevent its progression and complications; and (3) initially diagnose, evaluate, and manage other common renal diseases, such as nephrolithiasis and hypertension, encountered by primary care physicians.
Because the Concise Review for Clinicians contributions are now a CME activity, the answers to the questions will no longer be published in the print journal. For CME credit and the answers, see the link on our Web site at mayoclinicproceedings.com.