Impresionante revision del CME.

Primary care physicians (PCPs) should take a proactive stance in screening high-risk patients for the presence of chronic kidney disease (CKD). Once these individuals are identified, PCPs should provide guidance and interventional strategies designed to slow or reverse the progression of CKD. Confusion exists as to the most appropriate time to refer patients with diabetic nephropathy for renal consultation.1 Demands for nephrology services across the US are severely impacted by a shortage of specialists. In 2007, 6891 nephrologists were listed as full-time equivalent clinicians.2 Each nephrologist would be expected to provide care for 43,000 patients whose illnesses vary from acute infections to systemic lupus erythematosus. Even more worrisome is a futuristic view of the nephrology population. Although 235 nephrologists completed fellowship training in 2007, this number consistently falls approximately 200 trainees below the projections required to manage the need of renal patients in years to come. Thirty percent of all nephrologists are 55 years of age or older and may retire before our baby boom population is projected to add a significant financial burden to the end stage renal disease market place. Currently, 13% of the U.S. population has clinical evidence of CKD.3 Clearly, the burden of CKD detection, prevention and management will be shifting toward primary care specialties where the current patient-to-physician ratios are typically 1:1,000.4 Clinical decision making for CKD is challenging due to the heterogeneity of the kidney disease pathogenesis, variability of rates of disease progression and even genetic factors which ultimately may protect an individual from developing ESRD.5 Accurate prediction of CKD progression could facilitate patient-centered decision making which could ultimately slow and possibly reverse the course of diabetic nephropathy. Using two independent Canadian cohorts of 8391 patients with CKD stages 3-5 (3185, or 38% of whom had diabetes), Tangri, et al developed risk progression models for periods of 1, 3 and 5 years.6 Using a set of variables that are routinely measured in laboratories, disease progression may be accurately determined within a primary care practice. Factors which predict a more rapid rate of CKD progression over a period of 2-5 years from stage 3 to ESRD include: lower GFR, higher albuminuria, younger age, male sex, lower serum albumin, calcium and bicarbonate. A higher serum phosphate also predicts greater risk of ESRD. The kidney failure risk equation formula may be accessed online at: https://www.qxmd.com/calculate-online/nephrology/kidney-failure-

risk-equation. A free mobile phone app is also available on this web site.
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