Many people working in primary and secondary care are aware of the rising number of cases of chronic kidney disease (CKD).
There are currently 7.2 million adults affected by CKD in the UK, 1 in 10 people, with cases predicted to rise due to the ageing population and increasing epidemic of obesity and metabolic disease.
CKD remains underdiagnosed and undertreated and is predicted to be the fifth leading cause of death globally by 2040.
But a growing body of new research has shown that early identification and effective treatment can drastically slow down CKD progression and reduce the risk of end stage kidney disease. New treatments can also help to prevent heart attacks and stroke associated with kidney disease.
Treatment with Sodium-Glucose Transport Protein 2 (SGLT2) inhibitor drugs has been shown to reduce kidney failure, death from cardiovascular or kidney causes and doubling of serum creatinine by between 28 to 39 per cent.
Simple checks (such as regular blood and urine tests) and targeted treatment and control of risk factors (such as hypertension and type 2 diabetes) have also been proven to help prevent CKD.
Kidney Research UK has reported four key interventions that, collectively, could save 10,000 lives a year between 2023 and 2033. These include:
- earlier/ improved diagnosis of CKD
- improved CKD management
- use of SGLT2 inhibitors
- more kidney transplants.
Why it’s important to diagnose CKD
Dr Kieran McCafferty, Consultant Nephrologist at Barts Health NHS Trust and Clinical Co-chair of the London Kidney Network CKD Prevention Workstream, says that whilst preventing CKD with lifestyle advice, early diagnosis, and treatment of CKD has always been part of GP workload, new drug treatments for CKD will fundamentally alter the prognosis for people living with CKD.
“In the last 10 years, there's been lots of new medicines for early CKD, and these developments have brought into focus the need for early identification, coding, and interventions to prevent CKD progression,” says Dr McCafferty.
“We know that intervening early to prevent the devastating consequences of CKD, including death and dialysis, and cardiovascular disease, is key and particularly driven by lots of new therapies or medicines for kidney disease and, in particular, diabetic kidney disease, over the last 10 years.”
However, Dr McCafferty added that many people are not on these medicines because they haven’t been diagnosed (there are an estimated 86,000 people living with undiagnosed CKD in London alone, and in excess of one million undiagnosed people in England). “This is why it’s so important to identify people with kidney disease early, so we can get them on the therapies or medicines that will help,” says Dr McCafferty.
The London Kidney Network have developed CKD care pathways and a CKD resources package for primary care, in addition to a ‘What is CKD?’ information package for patients. These resources will support primary care to identify and optimise CKD management early. The pathways align with NICE and UK Kidney Association guidelines, and were co-created by primary and secondary care clinicians and other relevant stakeholders.
“We focused on primary care clinicians doing three key actions in three months to save lives,” says Dr McCafferty.
“In month one it is about maximising RAS/RAAS blockade, starting an ACE inhibitor, or ARB if indicated, and titrating to the maximum tolerated dose, as per the NICE guidelines.
“In month two it is about starting patients on SGLT2 inhibitors, and in month three, titrating further BP agents to target of < 140/ 90 mm Hg and in people with type 2 diabetes considering adding in finerenone.”
There are similar initiatives to this happening in Renal Networks all over the country.
“The aim is to get people on optimised therapy/medicines early because every day or week they are not on it, they are accruing risk for worsening kidney function,” says Dr McCafferty.
“We are very mindful about the challenges primary care are facing and trying it make it as easy as possible for primary care to do the right thing at the right time.”
How coding CKD makes management easier
“Coding CKD and having a consistent approach to coding CKD are important to help with appropriate diagnosing and capturing data,” says Linda Tarm, Clinical Co-chair of the London Kidney Network CKD Prevention Workstream.
“Coding CKD on the electronic health record helps with regularly recalling patients for review. It’s also a way to flag patients that need closer monitoring for better management. Coding is also associated with better risk factor management, for example we know that CKD cases coded in primary care have lower rates of unplanned hospital admission.’
The London Kidney Network has produced guidelines on CKD Coding in Primary Care.
The NICE Guidelines on CKD
The NICE Guidelines on CKD Assessment and Management (NG203) published in August 2021 set out how to prevent or delay CKD progression and reduce the risks of complications and puts the latest evidence into practice.
NICE also updated its guidelines on the use of SGLT2 inhibitors in type 2 diabetes and CKD in November 2022.
Here are five key things you need to know about the NICE CKD Guidelines:
- Screen people at risk of CKD using estimated GFR, and albumin to creatine ratio (ACR). This NICE table is a useful summary of who to screen for CKD and what tests to offer.
- Use the four-variable Kidney Failure Risk Equation instead of estimated GFR (eGFR) to guide referral to secondary care.
- Offer an SGLT2 inhibitor and optimised dose of ACE inhibitor or an ARB blocker to people with CKD and an eGFR of 20-45 ml/min/1.73 m2 or 45-90 ml/min/1.73 m2 and either a uACR of >22.6 mg/mmol or type 2 diabetes.
- Refer adults with CKD and a five-year risk of needing renal replacement of more than 5 per cent using the Kidney Failure Risk Equation for specialist assessment.
- No need to adjust the eGFR for people of African Caribbean or Black African origin.
How to talk to your patients about CKD
Dr Kristin Veighey is a clinical academic fellow in general practice and former nephrologist who is leading National Institute for Health and Care Research (NIHR) research into identifying and managing people with CKD at Southampton University and has set up a GP-led kidney clinic at Southampton’s Living Well Primary Care Network Partnership. Dr Veighey says, in her experience, patients tend to hate the term chronic kidney disease.
“Some people find out they have it on the NHS App and no doctor has mentioned it to them before, so they get up upset and end up in a spin. If they google it, they’ll see all this information about dialysis and about it being incurable and think they are going to die,” says Dr Veighey.
“So, I think you have to explain it in the right way, saying CKD is more common as you get older (but not just a normal part of ageing), and although you can’t reverse kidney damage, you can stabilise it and stop it getting worse with drug treatments, also stressing the effectiveness of the new treatments now available, as well as the importance of lifestyle changes such as a healthy diet, weight loss, and giving up smoking. It’s also worth stressing that only 2 per cent of people with CKD will end up needing dialysis.”
Dr Veighey says people who are health literate will ask lots of questions about what they can do to help themselves and be quite motivated. “What I worry about are the people we struggle to engage with – some of them could benefit from a one-to-one session with a practice nurse or health and wellbeing coach, if your practice has access to one. Obviously, the discussion has to be tailored to the individual though.
“It’s an opportunity to empower the patients, to talk to them about kidney disease, the medicines that can be prescribed, and offer information sources such as Kidney Care UK, which has more reassuring and less alarming information than what is on some health websites.”
“It’s worth bringing them back in for a longer consultation, or a series of consultations, so as not to overwhelm them with too much information at first.”
Medication pathway as per the NICE guidelines
- Optimised dose of ACE inhibitor, or an ARB blocker to people with Type 2 diabetes, an ACR of 30mg per mmol or more and who meet the marketing authorisation requirements (including relevant eGFR thresholds).
- Prescription of SGLT-2 inhibitors (these include the drugs empagliflozin and dapagliflozin).
- In people with type 2 diabetes, considering adding in finerenone.