Connecting the dots: caring for the patient with progressive CKD.

The approach we take to CKD in the KDIPPP Clinic represents a complicated regimen. It's not something we can do by ourselves, and it requires an integrated team approach. The team approach includes many different individuals all working together (see Fig. 2, p. 25). If we are to be successful, the initiative must include collaboration from the primary care physicians (PCPs), providers, and patients. Patients need to be screened yearly for serum creatinine, blood glucose, and blood pressure if they are at risk for CKD. Creatinine should be expressed as a GFR. Examine the urine to see if it is abnormal and check for microalbuminuria. The PCP, the patient, and the nephrologist must team up to establish the balance of care (see Fig. 3, p. 26). As the CKD patient progresses from the presence of risk factors to CKD Stages 1, 2, 3, and finally 4 and 5, the input from the PCP and the nephrologist gradually changes, from nearly full-time PCP care in the early stages to nearly full-time nephrology team care in the later stages. When patients migrate through progression, prevention, education, access placement, and RRT, the degree of involvement and interaction must be individualized. I recommend follow-up every year or two for patients in CKD Stages 1 and 2; follow-up every six months for Stage 3, and increased nephrology input as CKD progresses. We need to work together to treat these patients. If we do, then we're going to end up with better patient outcomes and better lives. The KDIPPP Clinic has been successful at meeting these goals.