Clinical systems and key messages for managing mild to moderate kidney disease

Understanding the prevalence of CKD means that strategies for identification, assessment and management need to be developed to help reduce the health burden that CKD poses in the United Kingdom. Around 6–8% of the population may have CKD stages 3–5, but not all patients with CKD need to be referred to or managed by nephrologists, although input from renal specialist nurses may be appropriate (Thomas 2011). These patients are at high risk of cardiovascular disease and should be managed appropriately, irrespective of referral to a nephrologist. The development of local guidelines enables progressive CKD and associated complications, such as cardiovascular risk and anaemia, to be managed in the community or general medical clinics and aims to ensure appropriate referrals to renal services. Referral of all patients with CKD stages 3–5 would overwhelm renal services and is not necessary. Anecdotal evidence suggested that referral rates to renal teams from primary care at least doubled following the introduction of eGFR reporting and a variety of methods to manage the increased numbers are being evaluated. Examples include employment of specialist renal nurses, or computerised systems to identify patients most at risk.

One such computerised system is the System for Early Identification of Kidney Disease (SEIK). This system, in east Kent, provides GPs with computerised decision support for the management of patients who have kidney disease. It offers patient specific advice on appropriate referral for kidney disease by using data extracted from primary care computer systems. The aim is to prevent or delay progression of kidney disease to end stage renal failure and reduce cardiovascular risk.

In general terms, it appears that local and national initiatives have together contributed to the improved understanding and management of CKD in primary care in the United Kingdom and as Stevens et al. (2012) have suggested, are showing signs of having made significant health gains. Box 6.1 shows the key messages that renal nurses can communicate to primary care teams.

The Renal Association and Royal College of GPs’ comprehensive guidance for CKD was published in 2005 and was followed in 2011 by clinical practice guidelines for detection, monitoring and care of CKD from the Renal Association. However, for GPs and nonspecialist healthcare providers to engage effectively with these guidelines, consideration must be made of the context of primary care and the current political and financial influences that affect care management. For example, information technology (IT) issues still need to be resolved to enable interface between biochemistry laboratories and GP surgeries, and to ensure adequate support for the GPs.

General Medical Services (GMS) Contract

A new contract for General Practitioners (GPs) in 2004 enabled GPs to be awarded points (related to income) if their surgery achieved specific indictors within a Quality and Outcomes Framework (QOF). With the advent of the Coronary Heart Disease (CHD), Diabetes and Renal NSFs and this new General Medical Services (nGMS) contract, it was important that work undertaken to improve the outcomes for patients with CKD was carried out in conjunction with primary and secondary care. Many of the QOF points concerning early detection and prevention of CKD are common to all three NSFs and the nGMS contract; these include protection strategies for blood pressure, urine testing for microalbuminuria, glycaemia and lipid control; not therefore adding dramatically to work already being undertaken.

The implementation of the nGMS contract in 2004 coincided with the drive to implement measures in primary and secondary care for early detection and prevention of the progression of CKD. The inclusion of tests in the Diabetes QOF, such as measurement of microalbuminuria and annual testing of creatinine for people with diabetes, has increased the quality of screening and documentation, potentially allowing easier identification for those people with varying stages of CKD caused by diabetes (Roland et al. 2012).

The QOF for CKD was introduced in April 2006, and was updated in 2012 to comprise five indicators as shown in Table 6.2. Points are attached to each indicator and determine the sum paid to each practice.

Table 6.2 The CKD QOF in the nGMS contract (2013–2014).

The indicators detailed in this section have been extracted from the 2013–2014 QOF guidance with the agreement of NHS Employers and the General Practitioners Committee of the BMA. Please note that QOF indicators are subject to change in subsequent years. The current, complete version of the guidance is available to download from the QOF section of the BMA web site. These pages also outline the process by which changes are made to the QOF http://bma.org.uk/practical-support-at-work/contracts/independent-contractors/qof-guidance (accessed 31 May 2013).

Although recent years have seen an overall improvement in practices achieving blood-pressure and proteinuria targets, there is a large variation in GP practices recording the prevalence of CKD. On average 4.1% of the population were recorded as having CKD in 2010 (NHS Information Centre 2011) and this may mean up to 30% of people with CKD are not known to primary care clinicians.

The impact of clinical guidelines for managing CKD in primary care

Since the publication of the first guidelines for managing CKD in primary care there remains scepticism about the impact and significance of diagnosing a patient with CKD, particularly as the concept of CKD is relatively new and patients with early disease are often asymptomatic (Brady and O’Donoghue 2010). One qualitative study (Crinson et al. 2010) found that primary care practitioners varied in their views of CKD. Some sought to implement the full clinical guidance, others only the pay-for-performance (QOF) targets. Nearly all practitioners had reservations as to whether CKD was really a disease and debated whether the diagnosis of CKD based on eGFR alone was appropriate. They also questioned whether CKD in older people was part of natural ageing and had experienced difficulty in explaining the condition to patients without frightening them. These findings were supported by Greer et al. (2012) who found that practitioners in the United States reported several patient, provider and system-level barriers that contributed to poor education about CKD in primary care. A study in the United Kingdom in 2012 found that there was still anxiety about the disclosure of early-stage CKD with patients. The tensions experienced in this study related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team (Blakeman et al. 2012). 

Care and Management of Mild to Moderate Kidney Disease (Stages 3a–3b)

This section provides a general overview of the care and management of people with stages 3a–b CKD, followed by a specific section on care and management of those with diabetes and CKD. The chance of developing CKD increases with age. People of African-Caribbean or south-Asian ethnic groups are also more likely to develop kidney disease. Chronic kidney disease appears to progress more rapidly in patients from lower socio-economic groups. A family history of CKD is also a risk factor. Patients can be directed to the NHS Choices Kidney Disease checker to see if they might be at risk of CKD www.nhs.uk/tools/pages/kidneydisease.aspx (accessed 20 May 2013).

Monitoring of CKD

Everyone at high risk should have an annual eGFR, to ensure that people with kidney disease are identified when the disease is still at an early stage. This is important because treatment of mild to moderate kidney disease with appropriate medicine management and changes in lifestyle can slow down kidney damage. Also early detection and treatment of CKD lessens the chance of it leading to CVD. An overview of tests for CKD management can be found at www.bjpcn-cardiovascular.com/download/3329 (accessed 20 May 2013).

How to explain the diagnosis of CKD

It is unfortunate that age-related decline in eGFR can be common, so it is important to note that an eGFR in the range 45–59, if stable over time and without any other evidence of kidney damage, is unlikely to progress or develop CKD-related complications.

Words used to explain this need to be chosen carefully. For example, it may be helpful to use the terms ‘kidney damage’ or ‘reduced kidney function’ rather than CKD, and to explain that kidney damage can be part of the normal ageing process. However, it is also important to explain that people with stage 3 CKD do need to be monitored and this will be carried out through an annual blood (eGFR) and urine (proteinuria) test. People with CKD stage 3A should have their names placed on the CKD Register and should be informed as such. Further information on how to explain CKD to patients can be found here www.bjpcn-cardiovascular.co.uk/download/3680 (accessed 20 May 2013).

Cardio-vascular disease (CVD) risk management

Cardio-vascular risk management is the main aim of care for people with stage 3 CKD, as both CKD and proteinuria are independent risk factors for CVD. A study by Debella et al. (2011) found that CKD is associated with a risk of death similar to that of established coronary artery disease and higher than that of diabetes mellitus. The authors also suggested that CKD is associated with a risk of myocardial infarction (MI) that is at least as much as that from diabetes mellitus.

In summary the following actions should be undertaken to reduce CV risk:

• Blood pressure control. The goal is to keep blood pressure below 140/90 mmHg or 130/80 mmHg (for those with diabetes and/or proteinuria) (see section on diabetes mellitus below). If the blood pressure target is not met on more than two occasions, it is recommended to prescribe a low dose of ACEI/ARB (e.g. ramipril 1.25 mg/day) and then monitor renal function and serum K+ after 5–10 days. Treatment can be increased progressively with monitoring. It is important to monitor renal function in case of renal function decline. This can happen when glomerular filtration pressure is dependent on angiotensin II –driven efferent arteriole tone (as in volume depletion or renal artery stenosis) (Steddon et al. 2006). However there may be up to 30 000 people with CKD who could benefit from ACE/ARBs and are not currently receiving them. As care for a patient on dialysis costs the NHS around £27 000 a year, and the cost of slowing down kidney deterioration is estimated to be £235 a year, timely prescription of antihypertensive therapy is crucial (Kerr 2012).
  
• Glycaemic control should be optimised according to individual targets.
  
• Salt intake should be assessed and reduced to 4–6 g/day
  
• Aspirin should be considered for secondary prevention in patients who have proven cardiovascular disease (National Institute for Health and Clinical Excellence 2008b). It is not contraindicated in renal impairment but there is a significantly increased risk of bleeding complications for patients on multiple antithrombotic agents.
  
• Weight reduction (aim for BMI < 30) and regular exercise (> 30 minutes/day) is also recommended.

Medicines review

A medicines review should be undertaken in any newly identified patient with CKD. Patients with CKD should be asked about over-the-counter and herbal medicines, to ensure medications are indicated and safe for the individual to take. It is important to emphasise that some medications can affect the kidneys – for example, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen – so it is best to check with a pharmacist before purchasing any over-the counter tablets. Metformin is excreted by the kidneys and has the potential to cause lactic acidosis. Many clinicians use metformin until eGFR is < 30 ml/min/1.73 m2, when it should be stopped altogether, whilst the dose might be reduced when eGFR 30–45 ml/min/1.73 m2. Special caution should be used when starting metformin in patients who are already on antihypertensive or diuretic therapy, or NSAIDs.

Referral

It is crucial to refer patients to a renal unit if eGFR < 30 or if there is rapidly decreasing kidney function. Renal units require at least one year to prepare people for dialysis, and once people with diabetes and CKD have an eGFR < 30 there may be a rapid decline in kidney function, especially if blood pressure and/or blood glucose are not well controlled.

The National Institute for Health and Clinical Excellence (2008a) guideline gives further details on referral to secondary care and a summary of indicators for referral is shown in Box 6.2.

Self-management

One of the best ways to effectively manage mild to moderate kidney disease is to empower patients with knowledge of their condition and likely outcomes. Most people with CKD spend the majority of time managing their own condition, supported by health care professionals for only a few hours each year. Both primary and secondary care nurses are well placed to facilitate opportunities for self-management such as

• Urine test: a reminder to come for urine tests (ACR) as required which will help identify if at risk of progressive CKD.
  
• Blood test: a reminder to come for blood tests to monitor kidney function as required.
  
• Blood-pressure control: to explain the importance of BP tablets not only for blood pressure control but also to delay progression of CKD. Explain the need to report side-effects, as high blood pressure is a key factor in the progression of CKD.
  
• Blood-pressure monitoring: to monitor their blood pressure at home but they will need advice on which machine to buy and training on how to do this.
  
• Smoking cessation.
  
• Diet: avoid processed, high-salt and high-fat foods.
  
• Medicine management:
  
  
  
  • give advice on buying tablets over the counter (particularly anti-inflammatory drugs);
    
  • patients should tell the pharmacist that they have chronic kidney disease.
  
  
• Lifestyle modification: taking exercise and keeping to ideal weight.

One quality-improvement project (Thomas and Loud 2012) aimed to reduce inconsistencies in CKD care and improve self-management opportunities for patients. At the end of the project a ‘Package of Innovation (POI) for Managing Kidney Disease in Primary Care’ was developed. This package was developed by a team of practitioners and people with experiences of kidney disease and other chronic conditions and aims to improve the quality of care of people with kidney disease in the community by helping the primary healthcare team to:

• identify people who have kidney disease in their practice;
  
• improve their knowledge and management of kidney disease;
  
• educate people about kidney disease;
  
• facilitate self-management in people who have kidney disease.

The package includes:

• details about how to validate a CKD register used in primary care;
  
• training packages for healthcare professionals on CKD management, quality improvement techniques and self-management facilitation;
  
• a training package that can be delivered by patients or healthcare professionals to people in a group education session to educate about kidney disease and encourage both self-management and collaboratively working with healthcare professionals;
  
• an information booklet and a DVD to help patients to look after their kidneys.

All materials can be used as per the step-by-step guide detailed in the package, although each is also a stand-alone item. The majority of the resources are freely available to download from https://support.kidneyresearchuk.org/packageofinnovation (accessed 31 May 2013).

Diabetes Mellitus

Good blood glucose control in individuals with type-1 diabetes mellitus has been shown some years ago to prevent or slow down the progression of renal disease (DCCT Research Group 1993). This landmark study demonstrated that a reduction in HbA1c (glycated haemoglobin) from 9.0% to 7.0% was associated with a 39% reduction in the occurrence of microalbuminuria and a 54% reduction in the occurrence of proteinuria over 6.5 years in patients with type-1 diabetes (DCCT Research Group 1993).

More recent research in type-2 diabetes mellitus indicated that tight blood pressure control was also crucial (United Kingdom Prospective Diabetes Study Group 1998). More recent studies reflect these findings: chronic kidney disease progression can be slowed by strict blood pressure (de Galan et al. 2009) and blood glucose control (Bilous 2008) prescription of medicines that modify the renin-angiotensin system (Araki et al. 2008) and lifestyle changes such as smoking cessation (Egede 2003). The National Institute for Health and Clinical Excellence (2008a) recommends annual monitoring of eGFR or more frequently if the eGFR is falling by > 5 ml/min/1.73 m2 per year. A summary of CKD management in people with diabetes is shown in Box 6.3 and is based on National Institute for Health and Clinical Excellence (National Institute for Health and Clinical Excellence 2008a) guidance.

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