n CME : Your SA Journal of CPD - Strategies for the early detection and management of chronic kidney diseaseâ??tertiary and primary health care working together : main article



  • There is a close relationship between chronic kidney disease (CKD) and cardiovascular disease (CVD) and both are rising worldwide.
  • In resource-challenged health systems we have to place a large emphasis on early detection and comprehensive high-quality management of chronic illnesses.
  • Most affected people have more than one chronic illness, e.g. hypertension and obesity, justifying integrated rather than disease- specific programmes.
  • Non-communicable diseases (NCDs) account for most deaths in South Africa and, together with HIV (a chronic illness), make chronic illnesses a major burden of illness and death in this country.
  • Research and subsequent clinical guidelines have significantly improved our focus for detecting, following and managing patients with CKD and CVD.
  • A clear, simple and integrated approach to risk factor and chronic disease management needs to be adopted, using chronic illness management models such as the Wagner Chronic Illness Care Model.
  • Primary health care clinicians and specialists have to work together as a team to ensure that patients with a significant disease burden are detected and treated.
  • An integrated model requires an understanding of existing resources capacity, when patients should be managed in primary care and when they should be referred for specialised care.


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