THOROUGH CRITICAL APPRAISAL
www.sin-italy.org/jnonline – www.jnephrol.com
The primary care physician: nephrology
interface for the identification and treatment
of chronic kidney disease
Paul E. Stevens1, Christopher K. Farmer1,
Stein I. Hallan2,3
Abstract
This article explores ways in which early identification
of chronic kidney disease (CKD) and promotion of the
concept of CKD as a modifiable risk can be achieved
through transcending traditional primary and secon-
dary care boundaries. National and regional strategies
aimed at early identification of CKD in the community
are reviewed, together with those aimed at implemen-
tation of management to reduce the risk both of pro-
gression of CKD and of complications.
Key words: Automated estimated GFR reporting, Car-
diovascular disease, Chronic kidney disease, Clinical
decision support, Screening
Introduction
It is 7 years since publications classifying and describing
the prevalence of chronic kidney disease (CKD) began to
proliferate in the literature, labeling CKD as a public he-
alth problem and suggesting that CKD is an epidemic (1-
13). Over this period, greater recognition of reduced kid-
ney function has been fostered through promotion of the
concept of estimating glomerular filtration rate (GFR) from
serum creatinine concentration using prediction equations.
Although this concept provides an easily and cheaply ap-
plied tool to alert clinicians to reduced kidney function and
is well established (14, 15), it has also been criticized (16).
Furthermore, use of the term disease has provoked some
understandably hostile reactions (17). Nevertheless, the
presence of CKD, even when defined by the 5-stage clas-
© 2010 Società Italiana di Nefrologia - ISSN 1121-8428
JNEPHROL 2010 ; 23 ( 01 ) : 23- 32
Department of Renal Medicine, East Kent Hospitals NHS
1
Trust, Canterbury - UK
Department of Renal Medicine, St. Olav University
2
Hospital, Trondheim - Norway
Department of Cancer Research and Molecular Medicine,
3
Faculty of Medicine, Norwegian University of Science and
Technology, Trondheim - Norway
sification, confers an increased risk of adverse outcomes
(18). The presence of albuminuria in addition to reduced
GFR increases this risk (19), and we know that lowering
albuminuria has a beneficial effect (20, 21). High blood
pressure is commonly associated with CKD, and we know
that reducing high blood pressure is also beneficial (22-24).
CKD is therefore an important risk modifiable concept.
So how do we promote identification of people with kidney
disease, with the tools currently available to us, and ad-
vance the concept of CKD as a modifiable risk factor? We
know that the vast majority of patients with CKD, as cur-
rently defined, are not under the care of nephrologists, and
neither do most of them need to be. How much of what ne-
phrology services do could be done just as effectively and
safely in primary care? Nephrology services play a num-
ber of roles for people with kidney disease: diagnosis and
treatment, control of risk factors for progression and pre-
paration of patients progressing to end-stage disease for
renal replacement therapy or conservative management.
Nephrology services are integral to the diagnosis and treat-
ment of complications of kidney disease, and have a well-
established role in the management of refractory hyper-
tension and the diagnosis and management of acid-base
and electrolyte disorders. What nephrology services do not
do, and are not positioned to do, is identify people with,
and at risk from, kidney disease. In longitudinal population
studies it has been clearly demonstrated that the majority
of patients with CKD have stable kidney function and that
the risk of cardiovascular death is far greater than the risk
of progression to end-stage renal disease (ESRD) (25-27).
The problem is that studies of practice patterns suggest
that CKD may not be appropriately recognized, both for
itself and as a risk modifiable concept (28-30). Furthermo-
23
Stevens et al: Primary care nephrologist interface for CKD
re, when CKD is identified, management and referral may
be suboptimal, and patient awareness of CKD, even in the
highest risk populations, is also suboptimal (31-33).
We know that the requirements for optimal care of indi-
viduals with disease include a scientific understanding of
disease, identification of those with, or at risk from, the di-
sease, a knowledge of the best therapies and strategies
available for management, the ability to deliver those the-
rapies in a timely manner and a supportive health care en-
vironment to deliver them from. These in turn require an
integrated approach encompassing disease awareness,
education, national policy and development of the neces-
sary care delivery systems. The aim of this article is to exa-
mine the integration between primary care and nephrology
in the delivery of kidney care.
National and regional strategies
A number of countries have begun to address the problem
of CKD through nationally orchestrated strategies. These
were collated through a survey on CKD “prevention” pro-
grams by the International Federation of Kidney Founda-
tions in 2005 and 2007. Of the 28 countries responding
(56% response), some form of screening activity was re-
ported in 24 (34).
Of note, Kidney Health Australia has a national task force
and has developed a national CKD strategy with a national
education program. This is focused on primary care but di-
stributed to all health professionals nationwide. They have
also developed an accredited practice nurse program. They
piloted an outreach program in a remote Australian Abo-
riginal community (Tiwi Islands) which reduced sickness,
hospital admissions, ESRD and natural deaths (35, 36).
The Australian outreach program contains both screening
and treatment components and has since been extended
to other Aboriginal areas in Australia and to South Africa
(37, 38). It involves mass community screening with the aim
of detecting high-risk groups and providing treatment, and
this has been complemented by the introduction of auto-
matic estimated GFR (eGFR) reporting (39).
In the United States, the National Kidney Foundation
(NKF) established their Kidney Early Evaluation Program
(KEEP) some years ago (40). KEEP offers free screening
and educational information for those 18 years and older
with high blood pressure, diabetes or a family history of
kidney disease. The program has screened over 100,000
subjects, and versions of the program have been introdu-
ced in other countries, including Japan and Mexico. The
NKF have also developed education materials for prima-
ry care providers, clinical practice tools and public and
24
patient education packages. The National Institutes of
Health’s National Kidney Disease Education Program was
developed in 2003 and includes educational components
for populations at high risk of CKD and a family reunion
outreach program (41).
Japan has had a legislated population-based CKD scree-
ning program since the 1970s, which has included scho-
ol children and company workers, and since 1983, adults
over 40 years. They are offered periodic health checks
which include urinalysis, and since 1992, measurement of
serum creatinine (42). The prevalence of a low GFR (<60
ml/min per 1.73 m2) in Japan is estimated to be 20% of the
adult population, and the prevalence of ESRD is currently
more than 2,000 per million population. More than 40% of
incident ESRD is due to diabetes mellitus (43). Since 2006,
screening of high-risk subjects has been introduced using
a version of KEEP.
Although starting later, the United Kingdom is now argua-
bly ahead of the game in national strategies aimed at early
identification and prevention of CKD. As a closed managed
care system with over 99% of the population registered in
primary care, the United Kingdom is very well placed to
create a structured delivery of health care for people with
kidney disease across the whole pathway, from risk all the
way through to ESRD. A number of key initiatives have
been introduced to help deliver this. The Renal National
Service Framework (a long-term strategy for improving
kidney care) highlighted the importance of testing kidney
function, of early identification of people at risk of CKD and
of integrating care pathways (44). Primary care in England
is now fully computerized and at least 97% of practices
receive laboratory results electronically (45). In April 2006,
kidney-specific indicators were introduced into the primary
care quality incentive program (the Quality and Outcomes
Framework - QOF) (46), together with implementation of
national eGFR reporting. More recently an ambitious va-
scular risk assessment and management program has been
proposed which is designed to ensure that everyone aged
between 40 and 74 years in the population has their va-
scular risk managed appropriately, encompassing coronary
heart disease, stroke, diabetes and kidney disease (47).
CKD guidelines
Several groups around the world have published guideli-
nes for the management of CKD in recent years (1, 48-54).
The most recent was from the UK National Institute for He-
alth and Clinical Excellence (NICE) (55). These guidelines
define the major components of care provision for CKD
and purport to offer best clinical advice for the early iden-
 JNEPHROL 2010 ; 23 ( 01 ) : 23- 32

tification and management of CKD. They are based on sy-
stematic evaluation of all published clinical and economic
evidence alongside expert consensus, taking account of
patient choice and informed decision-making. There are
some key differences in the NICE guidelines reflecting our
improved understanding of CKD. In the familiar stage 1-5
classification of CKD, stages 3-5 are denoted by level of
GFR with or without markers of kidney damage, and sta-
ges 1 and 2 require the presence of a marker of kidney da-
mage. The markers used include the presence of structu-
ral abnormalities and/or persistent hematuria, proteinuria
or microalbuminuria. Although using the familiar stage 1-5
classification of CKD, NICE recommends subdividing sta-
ge 3 into 3A (GFR 45-59 ml/min per 1.73 m2) and 3B (GFR
30-44 ml/min per 1.73 m2) and also using the suffix “p” in
all stages to denote significant proteinuria (Tab. I), as also
suggested by the Edinburgh consensus (51). The NICE
guidelines define significant proteinuria as an albumin to
creatinine ratio of ≥30 mg/mmol (equivalent to a protein to
creatinine ratio of ≥50 mg/mmol or 0.5 g proteinuria/day)
and recommends use of albumin to creatinine ratios to
quantify proteinuria. The rationale behind this recommen-
dation was based partly on scientific considerations in the
laboratory determination of urinary albumin versus total
protein, and partly because primary care providers alrea-
dy use, and are familiar with, albumin to creatinine ratios
through the surveillance of people with diabetes. Another
key difference from previously published guidance is the
recommendation of blood pressure ranges rather than
thresholds in the management of CKD, recommending a
systolic blood pressure range of 120-140 mm Hg in tho-
se with CKD and 120-130 mm Hg in those with diabetes
and CKD or an albumin to creatinine ratio ≥30 mg/mmol in
those without diabetes.
Implementation of eGFR reporting
Knowledge of GFR is essential for the diagnosis and ma-
nagement of CKD and is an easily translatable concept,
improving primary care provider’s interpretation and un-
derstanding of serum creatinine levels. Despite recom-
mendations to introduce automated reporting of eGFR,
a survey of laboratories in the United States published in
2008 found that only 38% of laboratories were reporting
an eGFR together with serum creatinine (56). In the Uni-
ted Kingdom, automated eGFR reporting was introduced

TABLE I
UPDATED CKD CLASSIFICATION FROM THE UK NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE)

eGFR
Stage Description Qualifier
(ml/min per 1.73 m2)

Kidney damage (presence of structural

1 ≥90 Kidney damage, N or ↑GFR
abnormalities and/or persistent haema-
turia, proteinuria or microalbuminuria) for
2 60-89 Kidney damage, mild ↓GFR ≥3 months

3A 45-59
Moderate ↓GFR ± other evidence
of kidney damage
3B 30-44
GFR <60 ml/min for ≥3 months ± kidney
Severe ↓GFR ± other evidence damage
4 15-29
of kidney damage

5 <15 Established renal failure

Use the suffix “p” to denote the presence of significant proteinuria when staging CKD (albumin to creatinine ratio [ACR] ≥30
mg/mmol, or protein to creatinine ratio [PCR] ≥50 mg/mmol). Source (55).
CKD = chronic kidney disease; eGFR = estimated glomerular filtration rate; N = normal.

25
Stevens et al: Primary care nephrologist interface for CKD

nationally from April 2006, using the 4-variable isotope

dilution mass spectrometry (ID-MS) traceable version of
the Modification of Diet in Renal Disease (MDRD) Study
equation (57). To reduce interlaboratory variation engen-
dered by differences in measurement of serum creatini-
ne, the UK National External Quality Assessment Scheme
(UKNEQAS) provides laboratories with correction factors
for the MDRD equation to adjust for method-related dif-
ferences compared to the ID-MS reference method. A
scheme similar to UKNEQAS has also supported Nordic
laboratories with correction factors and test sera since
2005/6.
Introduction of renal indicators in the
UK Quality and Outcomes Framework
One of the benefits of a publicly funded health care system
is the ability to introduce related initiatives aimed at identi-
fication of disease simultaneously throughout the system.
From April 2006 a CKD domain was included in the QOF
for the first time. This coincided with the implementation
of eGFR reporting and formed part of the drive to identify
people with CKD in primary care. Primary care providers
are required to produce a register of adults with stage 3-5

TABLE II
CKD INDICATORS IN THE UK QUALITY AND OUTCOMES FRAMEWORK

Payment
Indicator Points
stages

Records

The practice can produce a register of patients aged 18 years and over with CKD
6
(US National Kidney Foundation: stage 3 to 5 CKD). April 2006 onwards

Initial management

The percentage of patients on the CKD register whose notes have a record of
6 40%-90%
blood pressure in the previous 15 months. April 2006 onwards

Ongoing management

The percentage of patients on the CKD register in whom the last blood pressure
reading, measured in the previous 15 months, is 140/85 mm Hg or less. April 2006 11 40%-70%
onwards

The percentage of patients on the CKD register with hypertension and proteinuria
who are treated with an angiotensin-converting enzyme (ACE) inhibitor or angio-
5 40%-80%
tensin receptor blocker (ARB) (unless a contraindication or side effects are recor-
ded). April 2008 onwards

The percentage of patients on the CKD register whose notes have a record of an
albumin to creatinine ratio (or protein to creatinine ratio) value in the previous 15 6 40%-80%
months. April 2009 onwards

Points are financially remunerated.

CKD = chronic kidney disease.

26

CKD, to measure and record blood pressure annually, and
to record the percentage of people with CKD, hypertension
and proteinuria undergoing treatment with angiotensin-
converting enzyme (ACE) inhibitor or angiotensin receptor
blockers (ARBs). The renal indicators have been modified
and updated in successive years and now, from April 2009,
include the percentage of patients on the CKD register
whose notes record urine albumin to creatinine ratio (or
protein to creatinine ratio) within the previous 15 months
(Tab. II). Each indicator successfully met is rewarded with
points which are financially remunerated through the pri-
mary care contract.
What impact have these and related
initiatives had on identification of CKD
and referrals to renal services?
There is no doubt that the introduction and implementa-
tion of these measures has led to an increase in identifi-
cation and referral of people with CKD to specialist renal
services. Analysis of annual referral rates from primary
care in Kent between 2004 and 2008 shows a doubling
of referrals in the years following their introduction (Fig.
1). We knew from earlier work in our own area that prior
to introduction of these measures only 15% of people
with a median GFR of 29 ml/min per 1.73 m2 were actually
known to the renal service (26). An increase in referral was
therefore inevitable and is an expected and desired re-
sult. A similar picture has been observed wherever eGFR
reporting has been introduced, with increases in referral
ranging between 31%-48% (58-61). In general, patients
referred were older, and the increase in referral was pre-
dominantly in stage 3B and stage 4 patients, with a va-
riable effect on the quality of referral. As time progresses,
with the promotion of primary care education together
with the introduction of the necessary tools to aid mana-
gement, we envisage that primary care providers will gain
confidence in the management of stable CKD in much the
same way as they have with diabetes, and we would ex-
pect the referral rate to fall again. There is evidence from
around the world that this is an achievable goal through
implementation of various programs.
Programs and strategies aimed at
implementing best practice in CKD
identification and management
The introduction of measures enabling earlier identification
of CKD and the implementation of CKD guidelines requi-
JNEPHROL 2010 ; 23 ( 01 ) : 23- 32
Fig. 1 - Annual referrals to the Kent Kidney Care Centre (UK)
from primary care, 2004-2008.
re an infrastructure to ensure that there are both adequate
facilities to manage the increased recognition and referral,
and that those charged with providing the requisite health
care know what to do, when to do it, how to do it and to
whom. This involves both professional and patient educa-
tion and development of a CKD management and referral
program. One way of achieving this is through the creation
of CKD networks involving primary and secondary care
providers, public health and commissioners of services.
This is being done both locally and nationally but also ne-
eds to be allied to patient and public education, to encou-
rage greater understanding and to promote and empower
self-management of risk.
Around the world a number of different models for CKD
management encompassing collaborative working betwe-
en primary care physicians and nephrologists have been
developed. In Uruguay a national program encompassing
strategies aimed at education and raising awareness of
CKD risk factors has seen significant improvements in blo-
od pressure control and a reduction in rate of GFR decline
(62). In the state of New York, the introduction of a program
using a combination of practice enhancement assistants,
computer decision-making support and academic detailing
also led to markedly improved recognition and treatment of
CKD and its complications (63). Recognition of CKD incre-
ased by 58% and diagnosis of anemia by 34%, while use
of nonsteroidal anti-inflammatory drugs fell by 41%. A pilot
program of CKD educational intervention investigated its
effect on family physicians’ clinical competence and their
subsequent management of CKD in people with diabetes.
Measures of clinical competence included recognition of
disease and recognition of risk, correct use of diagnostic
tests and of therapeutic resources. All measures signifi-
cantly improved throughout the study and were associated
27
Stevens et al: Primary care nephrologist interface for CKD
with better blood pressure control, reduced proteinuria and
reduced rate of decline in GFR in the patients these physi-
cians cared for (64).
An alternative approach is the introduction of a primary ca-
re–based disease management program (DMP) utilizing an
algorithmic approach based on CKD management guideli-
nes (65). CKD stage 4-5 was identified using eGFR derived
from all serum creatinine values requested in routine clini-
cal practice in a defined population of 223,287. Patients
identified were invited to be enrolled in the program, risk
stratified and treated according to relevant algorithms. The
DMP was delivered by a community-based team of nur-
ses, dietitian and social worker seeking to influence 4 main
areas: patient education, medicines management, dietetic
advice and optimization of management to achieve clinical
targets. Patients (n=483) were enrolled into the program
from a population of 185,653 aged >15 years. The mean
age was 77.1 years (males 75.9 years, females 77.9 ye-
ars, p=0.088); 47% were male, and 29.7% were diabetic.
At enrolment, 60.4% of patients were receiving a statin,
52.5% of patients were receiving either an ACE inhibitor
or ARB. Significant improvements in cholesterol, systolic
blood pressure and diastolic blood pressure were achieved
after 9 months in the program, together with a reduced rate
of decline in GFR, suggesting that this DMP constituted an
effective method of identifying and managing patients with
CKD (Tab. III).
Clinical decision support systems
The existence of comprehensive primary care databases
lends itself to the development of clinical decision support
systems (CDSS) to aid identification, management and re-
TABLE III
EFFECTS OF THE INTRODUCTION OF A DISEASE MANAGEMENT PROGRAM FOR CKD
N=483 Baseline
Total cholesterol, mmol/L 4.6 (3.9-5.4)
Systolic blood pressure, mm Hg 139 (124-154)
Diastolic blood pressure, mm Hg 76 (69-84)
Fall in GFR*, ml/min per 1.73 m 2
3.69 (1.49-7.46)
All values are medians (interquartile range) of the data.
CKD = chronic kidney disease; GFR = glomerular filtration rate.
*Data for the fall in GFR from a subset of 317 patients with GFR data for 9 months prior to introduction of the disease manage-
ment program. Data taken from reference (65).
28
ferral of CKD. One example of this is the New Opportunities
for Early Renal Intervention by Computerised Assessment
(NEOERICA) project. The first phase of this project used
Morbidity Information Query and Export Syntax (MIQUEST),
a piece of UK Department of Health sponsored software, to
extract coded and structured data pertinent to CKD from
primary care databases in a representative sample of the
UK population (9). This enabled the developers to build a
comprehensive picture of the epidemiology of CKD in the
primary care population, which was then used, together
with evidence-based guidelines, to inform the development
of a detailed decision tree which forms the knowledge
base of the CDSS. The system interacts with primary care
computer systems, building a detailed picture of any gi-
ven patient with CKD encompassing any available data on
renal function, proteinuria, demographic and clinical data
including information on cardiovascular risk factors, coded
disease comorbidity and prescription data (Tab. IV). The
CDSS makes recommendations to primary care about sub-
sequent management and referral. In the example in Table
IV the introduction of the system to a primary care practi-
ce on the 10th of August, 2006, immediately highlighted a
patient with a rapidly progressive fall in GFR. In addition to
recommending immediate referral on the basis of absolute
level of GFR and blood pressure, the system also genera-
tes a graphical output of all previous GFR results and uses
a sequential algorithm to differentiate between stable and
unstable CKD. The aim is to provide timely advice about all
aspects of CKD management and referral, including timing
of subsequent blood and urine tests. In the example given,
the system also highlighted the need for improved blood
pressure and glycemic control. The CDSS has now been
tested in primary care and has been demonstrated to be
After 9 months p Value
4.2 (3.45-5.0) <0.01
130 (125-145) <0.05
71 (65-79) <0.01
0.32 (-2.61 to 3.12) <0.001
 JNEPHROL 2010 ; 23 ( 01 ) : 23- 32

transferable to areas of the country other than that in which
it was developed. The system is currently running live to
cover over 100,000 members of the primary care popula-
tion in 2 locations in the United Kingdom in 8 practices.
In one area over the last 12 months 18,635 of 76,087 of
the practice population (24.5%) have had serum creatini-
ne checked, of whom 2,851 had a GFR less than 60 ml/
min per 1.73 m2. Of these, 251 were coded on the primary
care systems as being known to renal services. Less than
a tenth of these (i.e., 234) required the involvement of ne-
phrology (either for discussion or referral). Of the remainder,
139 required an additional test or change in medication,
and in 101 of these, this was simply a repeat measurement
of serum creatinine.
Early analysis suggests that use of the system has resulted
in a higher proportion of appropriate referrals from those
practices using the system compared with those who are
not. A longer period of follow-up is required to establish
whether it truly adds value in the management of CKD and
positively influences outcomes.
What can we conclude, and where do
we go from here?
Many of the measures described above have been imple-
mented concurrently, so it may be difficult in the future to
tease out the specific benefits of each strategy. What is
clear, however, is the need for a coherent strategy in terms
of primary care, laboratories and hospital providers of kid-
ney care. This strategy must also include patient groups

TABLE IV
EXAMPLE OUTPUT FROM A CLINICAL DECISION SUPPORT SYSTEM

Patient ID: Gender: Date of birth: Age: Assessed as stage 4 on:

23563 F xx/xx/xxxx 29 10/8/2006

Recommendation: Refer patient: Immediate: Unacceptable GFR decline: Stage 4 CKD with diastolic ≥120 mm Hg

Date Creatinine eGFR Other test results

08/12/2005 65 99 Blood Pressure 04/08/2006 190/120
07/07/2006 157 36 Haemoglobin 07/07/2006 8.4
27/07/2006 207 26 Potassium 27/07/2006 5.4
Calcium 07/07/2006 2.2
Phosphate 07/07/2006 1.19
Glucose 03/03/2006 4.7
HbA1c 03/03/2006 10.9
Proteinuria 12/9/2005 0
Cholesterol 08/12/2005 4.2
Folate 03/05/2006 10.1

Last medication issue recorded Further recommendations Readcode

Treat blood pressure

04/08/2006: Perindopril tablets 4 mg
Test for proteinuria Blood sugar
charts 7/12/2005
Start statin Diabetes
09/05/2006: Ferrous sulphate tablets 200 mg
HbA1c high review medication

CKD = chronic kidney disease; GFR = glomerular filtration rate.

29
Stevens et al: Primary care nephrologist interface for CKD
and care networks, guidelines, a comprehensive education
program and linkage of all areas through a system of com-
puterized clinical records. Clinical decision support tools
and disease management programs may further improve
the standard of care given to patients with CKD. They have
already had an effect on appropriate referral of patients
with CKD, there is a suggestion that they have also had an
effect on outcomes, and critically for health economies, ini-
tial analysis suggests that they are cost-effective (66). The
next step would then be to extend these programs into an
integrated vascular management strategy encompassing
CKD, diabetes and heart disease to deliver truly effective
structured health care transcending traditional boundaries.
Conflict of interest statement: No conflicts of interest.
Address for correspondence:
Paul E. Stevens
Consultant Nephrologist
Kent and Canterbury Hospital
Ethelbert Road
Canterbury, Kent CT1 3NG, UK
paul.stevens@ekht.nhs.uk
References
1. National Kidney Foundation. K/DOQI clinical practice guideli-
nes for chronic kidney disease: evaluation, classification, and
stratification. Am J Kidney Dis. 2002;39(Suppl 1):S1-S266.
2. Coresh J, Astor BC, Greene T, et al. Prevalence of chronic
kidney disease and decreased kidney function in the adult
US population: Third National Health and Nutrition Examina-
tion Survey. Am J Kidney Dis. 2003;41:1-12.
3. Levey AS, Eckhaardt KU, Tsukamoto Y, et al. Definition and
classification of chronic kidney disease: a position statement
from Kidney Disease: Improving Global Outcomes (KDIGO).
Kidney Int. 2005;67:2089-2100.
4. Chadban SJ, Briganti EM, Kerr PG, et al. Prevalence of kid-
ney damage in Australian adults: the AusDiab kidney study. J
Am Soc Nephrol. 2003;14(Suppl 2): S131-S138.
5. Verhave JC, Hillege HL, Burgerhof JG, et al; PREVEND Stu-
dy Group. The association between atherosclerotic risk fac-
tors and renal function in the general population. Kidney Int.
2005;67:1967-1973.
6. Amato D, Varez-Aguilar C, Castaneda-Limones R, et al. Pre-
valence of chronic kidney disease in an urban Mexican po-
pulation. Kidney Int. 2005; 97(Suppl):S11-S17.
30
7. Otero A, Gayoso P, Garcia F, de Francisco AL; on behalf of
the EPIRCE study group. Epidemiology of chronic renal di-
sease in the Galician population: results of the pilot Spanish
EPIRCE study. Kidney Int. 2005;68(Suppl 99):S16-S19.
8. Hallan SI, Coresh J, Astor BC, et al. International comparison
of the relationship of chronic kidney disease prevalence and
ESRD risk. J Am Soc Nephrol. 2006;17:2275-2284.
9. Stevens PE, O’Donoghue DJ, de Lusignan S, et al. Chronic
kidney disease management in the United Kingdom: NEOE-
RICA project results. Kidney Int. 2007;72:92-99.
10. Imai E, Horio M, Iseki K, et al. Prevalence of chronic kidney
disease (CKD) in the Japanese general population predicted
by the MDRD equation modified by a Japanese coefficient.
Clin Exp Nephrol. 2007;11:156-163.
11. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic
kidney disease in the United States. JAMA. 2007;298:2038-
2047.
12. Zhang L, Zhang P, Wang F, et al. Prevalence and factors as-
sociated with CKD: a population study from Beijing. Am J
Kidney Dis. 2008;51:373-384.
13. Coresh J, Stevens LA, Levey AS. Chronic kidney disease
is common: what do we do next? Nephrol Dial Transplant.
2008;23:1122-1125.
14. Stevens LA, Coresh J, Greene T, et al. Assessing kidney fun-
ction: measured and estimated glomerular filtration rate. N
Eng J Med. 2006;354:2473-2483.
15. Clarke WF, Macnab JJ, Chen SJ, et al. Evaluation of GFR
estimating equations in the general community: implications
for screening. Clin J Am Soc Nephrol. 2006;1:787-795.
16. Giles PD, Fitzmaurice DA. Formula estimation of glomerular
filtration rate: have we gone wrong? BMJ. 2007:334:1198-
1200.
17. Glassock RJ, Winearls C. An epidemic of chronic kidney di-
sease: fact or fiction? Nephrol Dial Transplant. 2008;23:1117-
1121.
18. Go AS, Chertow GM, Fan D, et al. Chronic kidney disease
and the risks of death, cardiovascular events, and hospitali-
sation. N Engl J Med. 2004;351:1296-1305.
19. De Jong PE, Gansevoort RT. Fact or fiction of the epidemic
of chronic kidney disease: let us not squabble about estima-
ted GFR only, but also focus on albuminuria. Nephrol Dial
Transplant. 2008;23:1092-1095.
20. Jafar TH, Stark PC, Schmid CH, et al. Progression of chronic
kidney disease: the role of blood pressure control, proteinu-
ria, and angiotensin-converting enzyme inhibition: a patient-
level meta-analysis. Ann Intern Med. 2003;139:244-252.
21. Ruggenenti P, Perna A, Remuzzi G. Retarding progression
of chronic renal disease: the neglected issue of proteinuria.
Kidney Int. 2003;63:2254-2261.
22. Sarnak MJ, Greene T, Wang X, et al. The effect of a lower
target blood pressure on the progression of kidney disease:
long-term follow-up of the Modification of Diet in Renal Dise-
ase study. Ann Intern Med. 2005;142:342-351.
23. Wright JT Jr, Bakris G, Greene T, et al. Effect of blood pressu-
re lowering and antihypertensive drug class on progression

of hypertensive kidney disease: results from the AASK trial.
JAMA. 2002; 288:2421-2431.
24. Berl T, Hunsicker LG, Lewis JB, et al. Impact of achieved
blood pressure on cardiovascular outcomes in the Irbe-
sartan Diabetic Nephropathy Trial. J Am Soc Nephrol.
2005;16:2170-2179.
25. Drey N, Roderick P, Mullee M, et al. A population-based stu-
dy of the incidence and outcomes of diagnosed chronic kid-
ney disease. Am J Kidney Dis. 2003;42:677-684.
26. John RI, Webb MC, Young A, et al. Unreferred chronic
kidney disease: a longitudinal study. Am J Kidney Dis.
2004;43:825-835.
27. Keith DS, Nichols GA, Gullion CM, et al. Longitudinal follow-
up and outcomes among a population with chronic kidney
disease in a large managed care organization. Arch Intern
Med. 2004;164:659-663.
28. Boulware LE, Troll MU, Jaar BG, Myers DI, Powe NR. Identi-
fication and referral of patients with progressive CKD: a na-
tional study. Am J Kidney Dis. 2006;48:192-204.
29. Lea JP, McClellan WM, Melcher C, Gladstone E, Hostet-
ter T. CKD risk factors reported by primary care physi-
cians: do guidelines make a difference? Am J Kidney Dis.
2006;47:72-77.
30. Fox CH, Brooks A, Zayas LE, McClellan W, Murray B. Prima-
ry care physicians’ knowledge and practice patterns in the
treatment of chronic kidney disease: an Upstate New York
Practice-based Research Network (UNYNET) study. J Am
Board Fam Med. 2006;19:54-61.
31. Nickolas TL, Frisch GD, Opotowsky AR, Arons R, Radha-
krishnan J. Awareness of kidney disease in the US popu-
lation: findings from the National Health and Nutrition Exa-
mination Survey (NHANES) 1999 to 2000. Am J Kidney Dis.
2004;44:185-197.
32. Coresh J, Byrd-Holt D, Astor BC, et al. Chronic kidney dise-
ase awareness, prevalence, and trends among U.S. adults,
1999 to 2000. J Am Soc Nephrol. 2005;16:180-188.
33. Jurkovitz C, Franch H, Shoham D, Bellenger J, McClel-
lan W. Family members of patients treated for ESRD have
high rates of undetected kidney disease. Am J Kidney Dis.
2002;40:1173-1178.
34. Smith JM, Mott SA, Hoy WE. Status of chronic kidney
disease prevention programs: International Federation
of Kidney Foundation Members 2005/2007. Kidney Int.
2008;74:1516-1525.
35. Hoy WE, Baker PR, Kelly AM, Wang Z. Reducing premature
death and renal failure in Australian Aboriginals: a communi-
ty-based cardiovascular and renal protective program. Med
J Aust. 2001;174:201-202.
36. Hoy WE, Wang Z, Baker PR, Kelly AM. Reduction in natural
death and renal failure from a systematic screening and tre-
atment program in an Australian Aboriginal community. Kid-
ney Int. 2003;63:S66-S73.
37. Hoy WE, Kondalsamy-Chennakesavan S, Scheppingen-
Smith J, Sharma S, Katz I. A chronic disease outreach
JNEPHROL 2010 ; 23 ( 01 ) : 23- 32
program for Aboriginal communities. Kidney Int. 2005;
68:S76-S82.
38. Katz I, Hoy WE, Kondalsamy-Chennakesavan S, et al.
Chronic kidney disease management: what can we le-
arn from South African and Australian efforts? Blood Purif.
2006;24:115-122.
39. Mathew TH. Chronic kidney disease and automatic reporting
of estimated glomerular filtration rate: a position statement.
Med J Aust. 2005;183:138-141.
40. National Kidney Foundation. KEEP: Kidney Early Evalua-
tion Program. New York: National Kidney Foundation; 2009.
Available at: http://www.kidney.org/news/keep/index.cfm.
Accessed December 20, 2009.
41. Hostetter TH, Lising M. National Kidney Disease Education
Program. J Natl Med Assoc. 2002;94(8 Suppl):72S-75S.
42. Imai E, Yamagata K, Iseki K, et al. Kidney disease screening
program in Japan: history, outcome, and perspectives. Clin J
Am Soc Nephrol. 2007;2:1360-1366.
43. Iseki K. Chronic kidney disease in Japan. Intern Med.
2008;47:681-689.
44. UK Department of Health. National Service Framework for
Renal Services: Part Two: chronic kidney disease, acute re-
nal failure and end of life care. UK Department of Health;
2005. Available at: www.dh.gov.uk/renal.
45. NHS Connecting for Health. PMIP weekly status report. UK
National Health Service; 2007. Available at: http://www.con-
nectingforhealth.nhs.uk/systemsandservices/pathology/edi-
fact/pmip/reports. Accessed December 20, 2009.
46. The Information Centre for Health and Social Care. The Qua-
lity and Outcomes Framework. UK National Health Service;
2009. Available at: http://www.ic.nhs.uk/statistics-and-data-
collections/audits-and-performance/the-quality-and-outco-
mes-framework. Accessed December 20, 2009.
47. Putting Prevention First: vascular checks: risk assessment
and management. UK Department of Health. Available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publica-
tions/PublicationsPolicyAndGuidance/DH_083822. Acces-
sed February 15, 2009.
48. Joint Specialty Committee for Renal Disease Royal College
of Physicians of London and the Renal Association. Chronic
kidney disease in adults: UK guidelines for identification, ma-
nagement and referral. London: Royal College of Physicians
of London; 2006. Available at: http://www.renal.org/CKD-
guide/ckd.html. Accessed December 20, 2009.
49. Burden R, Tomson C. Identification, management, and refer-
ral of adults with chronic kidney disease: concise guidelines.
Clin Med. 2005;5:635-642.
50. The Renal Association. The short CKD eGuide, derived from
the UK CKD Guidelines (2005). Revised 2009. Available at:
http://www.renal.org/eGFR/eguide.html. Accessed Decem-
ber 20, 2009.
51. Archibald G, Bartlett W, Brown A, et al. UK consensus con-
ference on early chronic kidney disease, 6 and 7 February
2007. Nephrol Dial Transplant. 2007;22:2455-2457.
31
Stevens et al: Primary care nephrologist interface for CKD
52. Clinical Resource Efficiency Support Team. Guidelines
for chronic kidney disease in Northern Ireland. Belfast:
CREST Secretariat; 2006. Available at: www.crestni.org.
uk/chronic-kidney-disease-guidelines.pdf. Accessed De-
cember 20, 2009.
53. Caring for Australasians with Renal Impairment (CARI). Pre-
vention of progression of chronic kidney disease guidelines.
Available at: http://www.cari.org.au/guidelines.php. Acces-
sed December 20, 2009.
54. Diagnosis and management of chronic kidney disease: a na-
tional clinical guideline. Available at: http://www.sign.ac.uk/
pdf/sign103.pdf. Accessed February 15, 2009.
55. National Institute for Health and Clinical Excellence. Early
identification and management of chronic kidney disease
in adults in primary and secondary care. Available at: http://
www.nice.org.uk/Guidance/CG73. Accessed December 20,
2009.
56. Accetta NA, Gladstone EH, DiSogra C, Wright EC, Briggs M,
Narva AS. Prevalence of estimated GFR reporting among US
clinical laboratories. Am J Kidney Dis. 2008;52:778-787.
57. UK Department of Health. Estimated glomerular filtration
rate (eGFR). Available at: http://www.dh.gov.uk/en/Heal-
thcare/NationalServiceFrameworks/Renal/RenalInformation/
DH_4133073. Accessed December 20, 2009.
58. Noble E, Johnson DW, Gray N, et al. The impact of auto-
mated eGFR reporting and education on nephrology service
referrals. Nephrol Dial Transplant. 2008;23:3845-3850.
59. Torregrosa I, Solis M, Pascual B, et al. Implementation of a
nephrology–primary health care joint protocol for the mana-
gement of chronic renal disease: preliminary results. Nefrolo-
gia. 2007;27:162-167.
32
60. Aghaie-Jaladerany H, Cowell D, Geddes CC. The early im-
pact of the United Kingdom chronic kidney disease (CKD)
guidelines on the number of new attendances at renal clinics.
Scott Med J. 2007;52:28-31.
61. Wyatt C, Konduri V, Eng J, Rohatgi R. Reporting of estimated
GFR in the primary care clinic. Am J Kidney Dis. 2007;49:634-
641.
62. Renal Health Care Committee. Results of the National Renal
Healthcare Program in Uruguay. Renal Health Care Commit-
tee 2004-2007. Available at: http://www.nefrouruguay.com/
content/mazzuchi.pdf. Accessed February 15, 2009.
63. Fox CH, Swanson A, Kahn LS, Glaser K, Murray BM. Im-
proving chronic kidney disease care in primary care practi-
ces: an Upstate New York Practice-based Research Network
(UNYNET) study. J Am Board Fam Med. 2008;21:522-530.
64. Cortés-Sanabria L, Cabrera-Pivaral CE, Cueto-Manzano
AM, et al. Improving care of patients with diabetes and CKD:
a pilot study for a cluster-randomized trial. Am J Kidney Dis.
2008;51:777-788.
65. Richards N, Harris K, Whitfield M, et al. Primary care-based
disease management of chronic kidney disease (CKD), ba-
sed on estimated glomerular filtration rate (eGFR) repor-
ting, improves patient outcomes. Nephrol Dial Transplant.
2008;23:549–555.
66. Klebe B, Irving J, Stevens PE, et al. The cost of implementing
UK guidelines for the management of chronic kidney disea-
se. Nephrol Dial Transplant. 2007;22:2504-2512.
Received: February 28, 2009
Revised: May 27, 2009
Accepted: June 01, 2009