Chronic Kidney Disease (CKD)

Chronic kidney disease (CKD) is when there has been long term damage to the kidneys leading to reduced kidney function. The rate of CKD within the population is increasing at an alarming rate in part due to more people developing diabetes and hypertension. CKD is predicted to be the 5th highest cause of premature death by 2040 within the UK and currently affects up to 10% of the population. (Kidney Research UK)

Diagnosis

In the primary care setting CKD is diagnosed by a blood test measuring the creatinine and estimated glomerular filtration rate (eGFR), and a urine sample measuring the albumin:creatinine ratio (ACR). Two tests taken a minimum of 3 months apart will confirm CKD rather than a potential acute kidney injury (AKI).

CKD is referred to as a silent killer as in the early stages there are rarely any symptoms which is why it is so important to screen people in high-risk groups. Most people diagnosed with CKD will not reach end stage but having CKD significantly increases the risk of cardiovascular death. The main treatments aim for CKD are to slow down disease progression and reduce the risk of cardiovascular death. If people are coded appropriately when they are diagnosed with CKD, then they are more likely to receive the correct treatment, and their risk of death is reduced. There are 40,000 – 45,000 premature deaths in the UK every year due to CKD.

Ethnic minority communities are five times more likely to develop CKD than other groups as are people over 60 years and those who are obese. Screening should not be carried out because of these factors alone. CKD also disproportional affects people living within the most deprived areas.

The London kidney network has development a 30-minute educational package helping to explain why. A certificate is available on completion:

Health Inequalities in Kidney Care

Risk Factors and Screening:

People with the following conditions should be offered and encouraged to have screening for CKD with both a blood and urine test for their risk of disease progression to be accurately predicted:

  • Diabetes
  • Hypertension
  • Previous acute kidney injury (for 3 years even if function has returned to normal)
  • Cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease, cerebral vascular disease)
  • Structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
  • Multisystem diseases with potential kidney involvement e.g. systemic lupus erythematosus
  • Gout
  • Family history or end-stage renal disease (GFR below 15, dialysis or renal transplant) or hereditary kidney disease
  • Incidental finding of haematuria or proteinuria
  • Long term use of medications that affect kidney function e.g. NSAIDs, Lithium

To form a diagnosis of CKD a repeat screen should be completed 3 months after the first.

Talking to Patients About CKD:

A diagnosis of CKD can create worry and anxiety and have an impact on all aspects of someone’s life from concerns about travel insurance, an increased medication burden and life expectancy. If a new diagnosis of CKD is made, then in addition to coding it is important that this is explained to the patient. They may find it reassuring to know that most people with CKD will unlikely reach end stage disease and that there are steps that can be taken to slow down the progression and protect against cardiovascular disease.

A helpful way of educating patients who have a GFR below 60ml/min about the benefits of medications can be using the Kidney Failure Risk Equation (KFRE). This is a calculation which is validated for use in the UK (using the link below as there are other versions) and available as a laboratory calculation in some areas. By inputting a patient’s age, gender, eGFR and ACR their risk of developing end stage renal failure within the next 2 and 5 years can be calculated.

If someone has a risk of 5% or higher of reaching end stage disease within the next 5 years, then they should be referred to Nephrology regardless of their eGFR. This is to identify and treat patients who are at risk of faster deterioration in their function.

Once the score is available you can then show the patient how much it can be decreased by controlling their blood pressure, prescribing an ACE inhibitor or ARB and SGLT2 inhibitor.

There are some patient information videos based on their calculation.

It’s important to make patients aware that starting some preventative medications is likely to result in an initial more rapid decline in function but that in the long term their rate of decline will be less.

Risk of Acute Kidney Injury (AKI) in CKD

Many incidences of AKI start in the community but with hospital an AKI is associated with increased mortality and prolonged hospital stay. People with CKD are at an increased risk of an AKI and therefore ‘sick day’ rules should be considered if they are unwell at home. They should be informed about the importance of being well hydrated.

If someone is admitted to hospital with an AKI, some of their medications may have been stopped. They may require a medication review once they are discharged home, particularly if their kidney function has improved.

Clinician Resources 

West Yorkshire guidance for the management of CKD includes diagnosing CKD, categorising, and monitoring CKD, when to refer to secondary care and the “4 Key Things in 4 Months to Save Lives” approach to medicines optimisation. It can be accessed here: West Yorkshire Guideline for the Management of Chronic Kidney Disease (CKD) for Adults

National NICE guidance can also be accessed here: Chronic kidney disease: assessment and management and Chronic kidney disease | Health topics A to Z | CKS | NICE

The Kidney Failure Risk Equation (KFRE) can be used to risk stratify patients for the progression to end-stage kidney disease, and we encourage its use at each review. The 5-year risk score helps assess the need for secondary care input, enabling timely and appropriate referrals. 

Optimization of RAASi Therapy Toolkit – International Society of Nephrology

The West Yorkshire SGLT2 inhibitor guidance provides essential information for clinicians considering starting an SGLT2 inhibitor for patients. It includes important cautions and contraindications, key side effects to discuss, and appropriate dosing based on renal function for each indication (including heart failure, type 2 diabetes, and CKD). It can be accessed here: West Yorkshire Guideline for the Safe and Appropriate Use of Sodium Glucose Co-Transporter 2 inhibitors (SGLT2-i) for Adults

SGLT2 inhibitors play an important role in CKD management, but clinicians must adopt a holistic, person-centred approach that considers polypharmacy, multimorbidity, and frailty. The Leeds guidance for Glycaemic Control for Older People with Type 2 Diabetes and Frailty and/or Multi-morbidity includes individualised HbA1c targets for patients with varying degrees of frailty, and considerations for prescribing. 

Cardiovascular disease risk is elevated in individuals living with CKD; therefore, consideration should be given to the optimisation of lipid lowering therapies. Further guidance can be found in the Leeds Summary of National Guidance for Lipid Management for Primary and Secondary Prevention of CVD. 

The above links can also be located in the Leeds ‘Chronic Kidney Disease’ template on EMIS and SystmOne. 

Advanced Care: Finerenone 

Finerenone is a non-steroidal mineralocorticoid receptor antagonist available for individuals living with CKD and Type 2 Diabetes who are optimised on standard care (RAAS blockade and SGLT2 inhibitor). 

For eligibility criteria, please refer to the West Yorkshire CKD guidance. Finerenone is now classified as ‘green’ meaning primary care clinicians with the appropriate knowledge and skills can initiate without the need for secondary care input: 

Patient Resources 

It is important that patients are involved in discussions about their CKD diagnosis, as many remain unaware of their diagnosis or the associated risks.  

Lifestyle advice is important as patients can be supported to lose weight if they have a raised BMI, stop smoking, follow a no added salt diet, exercise and maintaining tight blood pressure and glucose control.

Kidney Care UK and The National Kidney Federation have a wide variety of patient information leaflets which can be ordered or viewed on the website. Kidney Care UK offers free counselling and practical help for people with CKD. Kidney Care UK, the UK’s leading kidney patient support charity | Kidney Care UK

Here you can find resources tailored for patients to help them understand their CKD diagnosis and key considerations to note. 

Chronic kidney disease (CKD) | Kidney Care UK 

10 healthy habits for happy kidneys | Kidney Care UK 

Potassium in Your CKD Diet | National Kidney Foundation 

West Yorkshire ICB has acquired a license to Cognitant Kidney Essentials resources until May 2026. Kidney Essentials is a web based educational resource for people who wish to know more about chronic kidney disease (CKD), how it is managed and what to expect if you have the condition. The resources are available to be sent to patients in 6 different languages which are culturally sensitive and can be accessed here: www.healthinote.com/ckd-wyk   

SGLT2 Inhibitor Resources for Patients 

The Leeds Information for People on SGLT-2 Inhibitors patient information leaflet covers all indications, including heart failure, type 2 diabetes, and chronic kidney disease. It can be sent digitally or downloaded and printed: Information for People on SGLT-2 inhibitors 

An easy read format can also be accessed here: My ‘gliflozin’ medication 

It is important sick day rules are discussed with patients: Sick Day Medication Guidance in Chronic Kidney Disease 

SGLT2 inhibitor brand-specific patient information is also available: 

Dapagliflozin (Forxiga): 

Empagliflozin (Jardiance)