Conservative Treatment of Chronic Kidney Diseace (CKD) / 日本農村医学会雑誌

ABSTRACT

In Japan, the number of dialysis patients as of the end of fiscal 2007 has hit the 275,000 mark. The nation is now ahead of the rest of the world in the number of patients per million population. The largest problem that confronts us is that the enormous cost of dialysis is putting a great strain on the nation's finances. In addition, it should be mentioned that the quality of life of dialysis patients is aggravating. It is very rare for renal disease patients to receive kidney transplants, because only 200 kidneys are offered per year in Japan. So most of the patients have no choice but to depend on dialysis for the rest of their life.In the treatment of chronic kidney disease (CKD), it is important to for physicians to delay initiating dialysis as much as they can in Japan. In 1987, I began the programmed treatment of patients in a predialysis state with two nephrologists. The treatment is based on the “Toride guidelines for CKD”. There is an annual meeting of patients. Laboratory data and the history of medication are preserved in sheets.In the CKD clinic of our hospital, there are many devices for time-consuming. Full laboratory data apear quickly on the computer panel, and a clerk enters main data in patients, CKD records.The principles of the clinic iuclude control of office blood pressure and home blood pressure, mild restriction of protein intake, salt intake restriction, monitoring the diet from the data of 24 hours urine collection, control of hemoglobin concentration, serum bicarbonate and phosphate concentration. Reduction in urine protein excretion to less than 0.5 gram per day is done by dietary protein restriction, control of blood pressure and administration of angiotensin converting enzyme inhibitor or angiotensin receptor blocker.The outcomes of the Toride Cohort Study in the past 21 years are as follows1. Reduction in medical cost by slowing the progression of CKD;2. Reduction in the dialysis-to-non dialysis rate;3. Appearance of the “arrested” or “remission” cases; and;4. Detection of the new risk factors for progression of CKD such as hyperphosphatenia and metabolic acidosis by multivariate analysis.There is a bare possibility open for a CKD patient to receive the “right” treatment of CKD, because only four to five clinics adopting the Toride guidelines are available in Japan.Physicians in CKD clinics have to judge and adjust many variables. The clinics spend plenty of time and effort on the treatment of CKD.In Japan, the medical fee in clinics is dependent on the number of visiting patients and on the number and quality of laboratory examinations, so the physicians keep away from CKD clinics.For the reduction of cost of dialysis, spread of “right” treatment is needed. For spread of the treatment, additional medical fee per patient visit is necessary as incentive.