Early Identification and Management of Chronic Kidney Disease: A Narrative Review of the Crucial Role of Primary Care Practitioners

Abstract

Early-stage (stage 1-3) chronic kidney disease (CKD) has an asymptomatic presentation such that most people with CKD are unaware of their disease status and remain undiagnosed. CKD is associated with multiple long-term conditions (MLTC), or multimorbidity, the most common of these being cardiovascular disease, hypertension, and type 2 diabetes. Primary care practitioners (PCPs) are crucial in the early identification and management of patients with CKD. For individuals at high risk of CKD, measurements of estimated glomerular filtration rate, urine albumin-creatinine ratio, and blood pressure should be obtained regularly and recorded in a timely manner. The importance of lifestyle changes in the prevention and management of CKD should also be highlighted. A recent addition to the treatment of CKD in people with and without type 2 diabetes has been the recommendation by clinical practice guidelines of a sodium-glucose co-transporter 2 (SGLT2) inhibitor alongside a renin-angiotensin-aldosterone system inhibitor as foundational therapy. SGLT2 inhibitors prevent CKD progression and reduce fatal and non-fatal kidney and cardiovascular events, hospitalization for heart failure, and all-cause mortality, and they have a favorable safety and tolerability profile. However, uptake has been slow, particularly in people with CKD without type 2 diabetes. A multifaceted approach is required to ensure that people with CKD receive optimal kidney protection. Measures to raise awareness of the importance of early identification and intervention include local/national campaigns via social media and practice-based education; clinical education programs; integration of clinical decision support tools into electronic health records; detection programs built around electronic health records; and good interdisciplinary communication. PCPs at the forefront of multidisciplinary care are best placed to implement the evidence-based clinical practice CKD guidelines for lifestyle modification and guideline-directed medical therapy.

Keywords: Chronic kidney disease; Primary care practitioners; Sodium–glucose co-transporter 2 inhibitors.

Fig. 1

The burden of chronic kidney disease

Fig. 2

Aid to the early identification and optimal management of patients with CKD. Taken from the Chronic Kidney Disease (CKD) Early Identification and Intervention in Primary Care document—find the full document in the ISN-KDIGO CKD Early Identification & Intervention toolkit. Available at: https://www.theisn.org/initiatives/toolkits/ckd-early-screening-intervention/). Note that this aid was published before the 2024 updates to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines were published. Reproduced with permission

Fig. 3

Compared with non-initiation, initiation of SGLT2 inhibitors at eGFR 75 mL/min/1.73 m² could delay kidney failure (eGFR ≤ 10 mL/min/1.73 m²) by 15 years, while initiation at 45 mL/min/1.73 m² could delay kidney failure by 7.5 years. Adapted from Madero, M. et al. SGLT2 Inhibitor Use in Chronic Kidney Disease: Supporting Cardiovascular, Kidney, and Metabolic Health. Kidney Medicine 2024;6(8):100851 [29], under the terms of the Creative Commons CC-BY license. Initial eGFR decline over first 2 weeks estimated using eGFR slope data from DAPA-CKD acute phase (2-week eGFR change: dapagliflozin 10 mg, −3.70 mL/min/1.73 m²; placebo, −1.00 mL/min/1.73 m²). Projections are based on eGFR from week 2 to end of treatment (DAPA-CKD chronic phase) and assume linear progression of eGFR decline [30]. Example patients with initial eGFR of 45, 60, and 75 mL/min/1.73 m² used chronic eGFR slope for DAPA-CKD subgroup with eGFR ≥ 45 mL/min/1.73 m². eGFR at start of chronic phase for patient with initial eGFR 45 mL/min/1.73 m²: dapagliflozin 10 mg, 41.3 mL/min/1.73 m²; placebo, 44.0 mL/min/1.73 m²; eGFR at start of chronic phase for patient with initial eGFR 60 mL/min/1.73 m²: dapagliflozin 10 mg, 56.3 mL/min/1.73 m²; placebo, 59.0 mL/min/1.73 m²; eGFR at start of chronic phase for patient with initial eGFR 75 mL/min/1.73 m²: dapagliflozin 10 mg, 71.3 mL/min/1.73 m²; placebo, 74.0 mL/min/1.73 m². CKD chronic kidney disease, eGFR estimated glomerular filtration rate, SGLT2 sodium–glucose co-transporter 2