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)

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). 2 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 aims 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

NICE guidelines for the assessment and management of CKD are available here:

Overview | Chronic kidney disease: assessment and management | Guidance | NICE

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 in order for their risk of disease progression to be accurately:

  • 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. The may find it reassuring to know that most people with CKD will stage 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 60 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 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.

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

The National Kidney Federation also has a large selection of patient information leaflets which again, can be ordered or viewed online, information videos and practical support. National Kidney Federation

The Yorkshire and Humber Kidney Network have collated a number of patient information resources. A-Z of Hospital Services (sth.nhs.uk)

Treatment Guidelines

Lifestyle advice is really important is 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.

The Yorkshire and Humber Kidney Network hosted a webinar ‘Optimising Kidney Health for all’ which is available to watch here: Optimising Kidney Health for All (youtube.com)

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.