What Should Primary Care Physicians Do to Mitigate Chronic Kidney Disease?

By Vilmar Trinta Negrón | Interview done by Dr. Eddie Ortiz

You can see the full interview her: What Should Primary Care Physicians Do to Mitigate Chronic Kidney Disease?

 

What can primary care physicians do to mitigate its impact on the population?

At Provider Network Solutions, we join the international community during the month that celebrates World Kidney Day to educate about the importance of kidney health, the prevalence of chronic disease, and to promote preventive measures.

In this edition of Clinical Dialogue, the Chief Strategy and Clinical Officer of Provider PR, Dr. Eddie Ortiz (EO), spoke with nephrologist Dr. Ramón Señeríz Olivencia (RS) about the crucial role primary care physicians play in the comprehensive management of patients with chronic kidney disease, as well as best practices for its prevention. They also discussed how healthcare systems can address the growing burden of kidney disease.

According to Dr. Ortiz, this prevalent disease is exacerbated by a series of risk factors common on the island, such as the high prevalence of diabetes, hypertension, and obesity. All of these significantly contribute to the development and progression of kidney disease.

• EO: The unique combination of genetic, environmental, and lifestyle factors in Puerto Rico presents a complex landscape for healthcare providers, particularly primary care physicians, who are often the first point of contact for patients at risk of developing kidney disease. Despite its high prevalence, early detection and proper management remain key to slowing the progression of chronic kidney disease and improving patient outcomes.

How do we approach primary identification and prevention? When is the best time for screening, and what laboratory tests should we order?

• RS: At what age should we begin screening? According to guidelines, at age 40 for patients with a history of diabetes, high blood pressure, or a family history of kidney problems. For diabetics, which is a large population in Puerto Rico, screening should be done at the time of Type 2 diabetes diagnosis. We assess kidney function using creatinine or a (blood) BMP (Basic Metabolic Panel) or a CMP (Comprehensive Metabolic Panel) to determine where we stand.

• EO: From your perspective, are you seeing prevention efforts? Are the patients you receive diagnosed early, or are you seeing more advanced cases upon diagnosis?

• RS: Unfortunately, I am seeing more advanced cases. My care shifts focus, emphasizing preparation for what’s to come rather than preventing what could happen.

• EO: Specifically regarding laboratory tests, tell us about GFR (glomerular filtration rate test, a blood test that measures kidney function), the role of creatinine, and albumin. Provide more details on diagnostic tests.

• RS: Creatinine is a substance found in our muscles that is released and filtered by the kidneys, allowing us to estimate kidney function using a mathematical formula that calculates GFR or glomerular filtration rate. Based on this number, we classify kidney disease stages from 0 to over 90: Stage 1: More than 90%, Stage 2: 60% to 89%, Stage 3A: 59% to 45%, Stage 3B: 44% to 30%, Stage 4: Less than 29% down to 15%, Stage 5: 15% or less, requiring dialysis.

• EO: Proper classification is crucial. It influences management strategies and tools, including pharmacological interventions, referrals, multidisciplinary patient management, and coding. Each stage has a specific coding requirement, and at Provider, we work with billers and coders to ensure this condition is correctly classified. What tools and therapies do we have for treating different stages of kidney disease?

• RS: At different stages, we must also consider microalbuminuria or albumin in urine, which indicates how quickly a patient will progress from one stage to the next. We look at microalbuminuria in urine as a marker. Ideally, we should not excrete albumin. If albumin is present in the urine, it signals an issue in the kidney, suggesting rapid progression if left uncontrolled. The presence of albumin determines the severity of treatment initiation. Since the 1990s, we have recognized the importance of using angiotensin blockers, such as ARBs (angiotensin receptor blockers) like lisinopril or candesartan, for patients diagnosed at Stage 3 and beyond or for any diabetic patient. A newer therapy on the market involves SGLT2 inhibitors like Farxiga and Jardiance, which should ideally be started in all diabetic patients, with greater urgency for those with albuminuria who are already excreting protein through the kidneys. If albumin is not controlled, kidney deterioration will accelerate.

• EO: From a primary care perspective, when is the ideal time to establish a referral relationship and co-manage a patient with a nephrologist?

• RS: Ideally, any patient with albuminuria should be seen by a nephrologist—specifically, those with an albumin level above 300 mg per gram, regardless of filtration rate or chronic kidney disease stage. For non-albuminuric patients, referral is typically recommended at Stage 3A. However, diabetic patients are different; they can progress from Stage 3 to Stage 3B within a year. Personally, I like to see all diabetics in Stage 3A at least annually.

• EO: The exchange of information between specialists and primary care physicians is vital. One of the key issues we identify in our population is the impact of social determinants of health. We recognize the critical role of a multidisciplinary healthcare team, including social workers and nurses, in managing these patients. At Provider, we have a comprehensive diabetes management program delegated by our business partners, where we conduct case management and assess social determinants. The importance of a multidisciplinary team is crucial. What is your perspective on this?

• RS: My experience with a multidisciplinary team has been excellent. Patients improve much faster with this approach than they would without these resources. A 15- to 20-minute consultation allows us to provide some guidance, but a nutritionist can delve deeper, and a social worker can identify risk factors—whether due to lack of support or poor nutrition caused by inadequate resources. All these factors contribute to optimal patient care and achieving treatment goals.

• EO: The transition to Stage 4 is critical, as we need to begin discussing fistulas and the inevitability of dialysis. This is a degenerative condition with a defined clinical course. How important is preparation, and what are the basic elements of patient preparation and collaboration between primary care physicians and specialists during this transition?

• RS: This transition is very difficult. It is emotionally overwhelming for patients, and some experience clinical decline due to denial. Many refuse to accept the information. The key is for the primary care physician and nephrologist to work together to ensure the patient understands that we are here to support them. Our goal is to prepare them so they do not end up hospitalized due to the dialysis process. We guide them through the transition to ensure they are well-prepared, whether with a fistula or other modalities, so they reach that stage safely.

• EO: I know Puerto Rico faces greater barriers than many other jurisdictions. What is your perspective on transplantation? What opportunities exist for patients to receive a transplant, and what have you observed in Puerto Rico regarding transplantation?

• RS: There is significant room for improvement in Puerto Rico’s transplant system. We need to transplant many more patients. A large number of patients are on dialysis, and I estimate that less than 15% receive a transplant—many die before the process. A kidney transplant dramatically improves a patient’s quality of life. Those undergoing dialysis must do so three to four times a week. With a transplant, their life shifts to managing the transplant, resulting in substantial improvement.

• RS: For physicians, the most important aspect is identifying patients who will progress rapidly. From experience, poorly controlled diabetics with years of uncontrolled diabetes tend to deteriorate the fastest. Avoiding the use of anti-inflammatory medications and minimizing them as much as possible is crucial. Fenofibrates, which are commonly used for triglycerides, often need to be discontinued, as they can create the appearance of chronic kidney disease when the patient does not actually have it. For patients over 65, monitoring kidney function, avoiding excessive anti-inflammatory use, and staying well-hydrated are essential. Patients should also be wary of unproven herbal remedies. Hydration—drinking plenty of water—is key.

 

• EO: We appreciate Dr. Señeríz’s insights. He serves patients in the Menonita Health System, where Provider has a strong presence, and we hope to welcome him soon to our preferred network.