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June 4, 2013 Issue

Clinical Practice Points

Evaluation and Management of Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2012 Clinical Practice Guideline

This synopsis of a guideline from the Kidney Disease: Improving Global Outcomes (KDIGO) organization focuses on key recommendations pertinent to the identification, classification, monitoring, and management of chronic kidney disease (CKD) in adults.

Use this article to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below!
  • Review how to define and evaluate CKD.
  • Ask your residents how they monitor their patients with CKD. Look at the Figure—it provides a chart to guide you. Ask your residents if they think it is useful.
  • Review with your residents the interventions recommended to prevent disease progression.
  • Get CME for yourself! As long as you’re reviewing this article to help you prepare to teach, sign in and take the short CME quiz to claim your credit!

Sunscreen and Prevention of Skin Aging. A Randomized Trial

This trial found that individuals asked to apply sunscreen daily had less skin aging than those instructed to put it on at their discretion. No effect on aging was seen with the use of beta-carotene.

Use this study to:

  • Review the benefit of sunscreen use. A prior trial referenced in this paper found a reduction in skin cancer.
  • Ask your residents if they think discussing the prevention of skin aging is a priority in their practice. Many patients are concerned with and pay attention to issues related to appearance. Does its importance to patients make it a priority in the choice of what to emphasize when time during an office visit is short?
  • Discuss whether to provide the Summary for Patients in your residents’ outpatient practice. It discusses the study’s findings in layman’s language.

Update in Endocrinology: Evidence Published in 2012

The authors provide you concise summaries of essential papers in endocrinology published in the last year, including randomized trials of insulin glargine and bariatric surgery for the treatment of diabetes, the treatment of thyroid cancer, the frequency of monitoring bone mineral density, and more!

Use this update to:

  • Assign several residents a summary to present—5 minutes each. You can review multiple topics and their “clinical pearls” in a rapid fashion.
  • Plan similar activities in other internal medicine specialties. Make this a series you do each year. We’ve assembled these update reviews for you, organized by specialty topic.

In the Clinic: : Care of the Adult Cancer Survivor

This concise and eminently practical review asks—and provides answers to—questions all residents need to know.

Use this review to:

  • Answer the multiple-choice questions at the end as a way of starting the discussion.
  • Ask what a “survivorship plan” is and what the roles of primary care and specialty physicians should be in executing them.
  • Review cognitive, sexual, and other organ-system issues to be aware of when seeing a patient who has had prior treatment for cancer.
  • Discuss what surveillance is appropriate in cancer survivors.
  • Get more CME for yourself! You’ve reviewed the topic to help you teach—so you might as well enter your answers to the questions and get CME credit!

Humanism and Professionalism

Married to Medicine

Play an audio recording of this issue’s On Being a Doctor in which Ms. Horowitz talks about moving her life—again—to a new home for yet another phase of her husband’s medical training. How many of your residents have partners who have had to make sacrifices on account of residency training? Talk with your residents about the stresses this has placed on them. How would (or should) they influence their plans after residency training?


mksap16

A 32-year-old woman is evaluated during a new patient visit. She is healthy, exercises regularly without symptoms, and takes no medications. Medical history is unremarkable. Family history is notable for her father and paternal aunt who both have hypertension and chronic kidney disease. There is no family history of polycystic kidney disease. Her father began dialysis when he was 50 years old and now has a kidney transplant.

Physical examination and vital signs are normal.

Which of the following should be done to screen for chronic kidney disease?

A. 24-Hour urine collection for creatinine clearance
B. Kidney ultrasonography
C. Radionuclide kidney clearance scanning
D. Serum creatinine, estimated glomerular filtration rate, and urinalysis

Answer: D. Serum creatinine, estimated glomerular filtration rate, and urinalysis

Key Point: Patients with a family history of chronic kidney disease should be screened for the disease

Educational Objective: Screen for chronic kidney disease.

This patient should be screened for chronic kidney disease (CKD) with a serum creatinine measurement, estimated glomerular filtration rate (GFR), and urinalysis. Recognizing patients at risk for CKD is imperative in a disease that can be asymptomatic. Certain medical history, including diabetes mellitus and hypertension, and predisposing risk factors should prompt screening for CKD. In particular, evaluation for diseases that can damage the kidneys directly (such as scleroderma) or can cause damage through their treatment (such as cisplatin) is indicated. A family history of CKD is a risk factor, as more evidence points to an inherited predisposition to CKD. A history of acute kidney injury (AKI) is recognized as a risk for future AKI and CKD. Various genitourinary abnormalities also can cause CKD. Screening for CKD includes measurement of the serum creatinine level and estimation of GFR as well as urinalysis to evaluate for blood, protein, and casts. Although evidence is lacking that targeted screening improves clinical outcomes, the National Kidney Foundation guidelines recommend targeted screening for CKD. Guidelines, however, do not support screening of the general population for kidney disease.

A 24-hour urine collection for creatinine clearance is generally used to obtain a precise estimation of kidney function, which is needed in circumstances such as the evaluation of living donor kidney transplant candidates. It is not a screening test for CKD because of the difficulty in obtaining the specimen correctly and its inconvenience.

Kidney imaging (usually ultrasonography) should be considered if the serum creatinine level or urinalysis is abnormal. Except for patients with a family history of polycystic kidney disease, it is not an initial screening study for CKD.

Radionuclide kidney clearance scanning is considered the gold standard for estimating GFR in healthy persons and in those with AKI. However, use of these studies is limited because of cost, lack of widespread availability, and operator technical difficulties.

Bibliography
Drawz P, Rahman M. In the clinic. Chronic kidney disease. Ann Intern Med. 2009;150(3):ITC2-1-ITC2-15. PMID: 19189903

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.

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