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Improving Patient and Provider Discussions in CKD
Managing CKD: How to Improve Patient–Provider and Provider–Provider Discussions

Released: November 21, 2023

Chuck Vega
Chuck Vega, MD, FAAFP
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Key Takeaways
  • Patients with CKD should be referred to nephrology when urine albumin levels hit 300 mg/g or they are diagnosed with stage 3b disease.
  • Effective management of these patients, who are seeing specialists, requires effective communication between all providers.
  • Although PCPs may see these patients the most, they cannot simply rely on specialists to meet every patient need.

In a previous ClinicalThought commentary on chronic kidney disease (CKD), I discussed the need for globalized education and shared decision-making to improve the management of and outcomes for patients with this disease. Here, I would like to go into more detail about when to refer to a nephrologist and what to do when complications in care arise.

Referring to Nephrology
There is a heat map that is a great resource for learning of the risks associated with various estimated glomerular filtration rate and albuminuria levels. In addition, it will tell healthcare professionals (HCPs), including primary care providers (PCPs), when they should refer patients to a specialist. For many patients, particularly those with severe albuminuria, HCPs should refer to nephrology early for evaluation so their health does not worsen, which could pose risk to the kidneys and cardiovascular system. 

It is reasonable to refer patients when they have urine albumin levels above 300 mg/g. It is also reasonable to refer at stage 3b CKD. If your local nephrologist wants you to refer at a different stage, talk it out with them. But, in using shared decision-making strategies, I think patients need to be involved in these discussions, as well.

Optimizing Patient–Provider and Provider–Provider Communication
Some patients want to engage with their care team, whereas others may not. In addition, patients may be facing barriers to care that will need to be addressed to ensure that they can access the treatment they need. Therefore, communication is critical. For example, you do not want to start patients on medication that contradicts what nephrology or another specialty has them taking. All members of the healthcare team need to be clear about what they are doing and why they are doing it; otherwise, one may really put a patient at risk for significant adverse events.

Poor communication between HCPs can hurt patients. An example: You prescribe an angiotensin receptor blocker, and the patient sees his nephrologist 1 week later. The patient is not clear with his nephrologist about what medications he is currently taking. (This happens very often in terms of knowing the name, dose, and drug class of each prescription.) So, the nephrologist starts the patient on an angiotensin-converting enzyme inhibitor and finerenone at the same time. Please remember that CKD itself is associated with hyperkalemia, and now that patient—who had a baseline serum potassium of 5.2 mEq/L—shoots to 6.4 mEq/L and develops symptoms, leading him to present to the emergency department. Fortunately, these are all avoidable medical errors—but to avoid them, one must start with good communication.

When patients have something in their medical record that does not seem right, that is a really important time to communicate with them. Maybe you know your patient saw a nephrologist recently, so you ask the nephrologist why she pulled the patient off the renin–angiotensin system inhibitor when it was working well. The patient’s blood pressure is controlled, and he still has electrolytes from 2 weeks ago and looks fine. What is going on here? This is where communication needs to occur.

Ideally, you work in a health system where you can see care notes and therefore understand the rationale behind the treatment decisions of other HCPs. Failing that, it is best to electronically notify the HCP in question to say: "Hey, I saw this. What's going on?” I often ask for the clinical reasoning behind the decision because there is often something I am missing, such as a patient preference or esoteric adverse event. If the HCP is outside your health system, then give him or her a call. I often provide my cell phone number and have a brief conversation with the HCP to make my care provision more efficient. Potentially not understanding someone else’s clinical reasoning and making more mistakes or compounding mistakes can really put patients in danger. Conversely, exchanging ideas with other HCPs is often refreshing and helps us work better as a team.

Empowering Patients and Their Caregivers
One important member of patients’ care team is their caregiver—somebody who is really supporting them. Often, this individual is a family member, but caregivers also can be close friends. Therefore, it is important to do medication reconciliation with caregivers, as well. Patients should be empowered to do so, but caregivers can help fill in the gaps.

In my practice, we have a lot of complex patients who take multiple medications. It can be challenging to keep patients and their caregivers up to speed on the benefits and risks of each prescription. This truly is asking a lot from our patients. What can help is telling patients to bring all their medications to every visit. The greatest technology in my practice is a brown paper bag. This way, I get to see what is really in their medicine cabinet, and I ask for everything, including supplements and expired drugs.

Polypharmacy is common among older adults. With CKD management, this practice can turn out to be harmful because patients may be taking nephrotoxic drugs without realizing it. It really takes due diligence on the PCP’s behalf to keep our patients safe and on the right track to achieve the best outcomes.

Practicing What You Preach
Sometimes the question arises in team-based care as to who is taking ownership of a patient’s care—and that is an understandable occurrence. I think primary care tends to think of themselves as distributors, so they are going to be the quarterback of the team and watch over things.

That is an okay approach, but it puts patients at risk of clinical inertia. When I see a clear need, I go ahead and put in for that necessary prescription. In doing so, I state in my assessment plan why I made the prescription and ensure that the nephrologist, endocrinologist, and/or cardiologist are all copied so we are all on the same page. Lost opportunities are unfortunately what costs people their renal function.

PCPs should not practice clinical inertia. Break out of that mold. Most patients’ visits are with primary care, so be the quarterback who also can run the ball and advance care directly. Your patients are going to be healthier from it. Just make sure you—the PCP or specialist—effectively communicate that decision to the entire care team.

Your Thoughts?
In your clinical practice, how is your communication with patients and members of their extended healthcare team? You can get involved by answering the polling question and posting a comment below.

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In your clinical practice, do you communicate with your patients’ other providers/specialists when managing their CKD?

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