Chronic Kidney Disease (CKD) in Primary Care
Dr Kathryn Griffin
Royal College of General Practitioners (RCGP) Clinical Champion for Kidney Care (CKD) and a GP principle with Unity Health in York.
CKD as we know it now has only been in existence for twelve years following the introduction of the staging system developed by the Kidney Disease Outcomes Quality Initiative based on eGFR. It was developed as a strategy to identify people with early kidney disease and put into measures to reduce progression and kidney failure.
In 2005 the NSF for Renal Disease recommended the reporting of eGFR calculated using the MRDR equation when creatinine values are reported and enabled the identification of people with CKD in primary care.
In 2006 CKD was included as a clinical domain in QOF, and in 2008 NICE published a Guideline on CKD management.
We have identified over 5% of the adult population with CKD and regularly monitor them in chronic disease clinics, assessing proteinuria with ACR and controlling hypertension.
Despite all this hard work, there continues to be concerns regarding over diagnosis and unnecessary patient anxiety caused by CKD. Only last summer an article in the BMJ by Moynihan and colleagues provoked a lively debate on this subject.
As the Clinical Champion for Kidney care and a member of the NICE Guideline Update Group you would expect me to be an enthusiast but as a practicing GP I am also aware of the issues concerning over diagnosis.
The partial update of the CKD guideline published this summer, makes recommendations to improve the accuracy of the diagnosis and will therefore enable us to be more confident with our patients. The new tests are described in these articles with a helpful fact sheet to print off for patients when they are introduced. It is important to focus on CKD associated with increased risk. We know that most people identified with CKD in primary care will also have other long-term conditions. The co-existence of CKD will increase the risk of cardiovascular disease and have implications when prescribing.
Recent evidence has demonstrated increased risk associated with even small levels of albumin in the urine, at levels previously described as mrcroalbuminuria. This increased risk of cardiovascular disease and progression are seen in people both with and without diabetes. A new grading system is recommended which includes 3 levels of albuminuria.
Acute Kidney Injury is a condition which is even younger than CKD, but is closely linked with CKD. People with CKD are at increased risk of AKI and extra care needs to be taken when people with CKD become unwell and hypovolaemic particularly if they are taking medications which interfere with the renin-angiotensin system. People with AKI may continue to have kidney function in the CKD range after the event, or are at risk of progressing to CKD in the future and should therefore have regular kidney function tests.
At present the Guideline Update offers suggestions for change but it will need further work on implementation before changes in formulae or blood tests are brought into use.
If you wish to learn more please consider that although there are several online learning modules on CKD they will all be undergoing a process of update, I know as I am trying to do a couple of them. Before you start a module make sure that it includes NICE CG182.
We have been very fortunate to be supported by the British Kidney Patients Association and are working with them to improve education for people with early CKD. This work will be undertaken by the two Clinical Support Fellows, May and Ridwann. Providing online and printed materials should make it easier discussing the diagnosis and management of kidney disease with our patients and their families.
In my time as Clinical Champion I hope to support my colleagues and improve the management of kidney disease in primary disease in primary care. I am aware of quality improvement activity across the country with centres of primary care research in Manchester, Oxford and Bristol. Within the Clinical Innovation and Research Centre (CIRC) we have developed a network of GPs who share at least some of my passion for the subject. If any of you would like to join, please send me an email. I am also happy to offer support to individuals and localities.
For further details on the work Dr Kathryn Griffith is doing as the RCGP Clinical Champion for CKD, please visit here.