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The role of primary care in chronic kidney disease
I was at my college reunion recently and, as is common at reunions, we were all exchanging what we did.
Perhaps a little to my surprise my GP friends and colleagues gave me some ‘clear’ views on chronic kidney disease and its utility.
Clearly, as a kidney specialist, I felt disappointed in the nature of that feedback but on reflection reconsidered how the success of the strategy for chronic kidney disease had been (imperfectly) communicated to fellow professionals. So how do I make the case?
A decade ago, one of the biggest problems that patients with end stage renal disease faced was late diagnosis and requiring dialysis as an emergency.
About one-third of patients started their time on dialysis in this way and yet there was a realisation that more could be done. The introduction of estimated Glomerular Filtration Rate (GFR) together with NICE guidance around CKD was a major step forward and now we can look back and see how that has improved care.
Not only has late presentation fallen to under 20 per cent (UK Renal Registry 16th Annual Report 2013) but also in England the rate of people starting renal replacement therapy has plateaued at about 110pmp (per million population) for the last five years.
For me, that is a success of the management of CKD, most of which resides in primary care. Improved recognition and timely referral with an understanding that blood pressure control is vital have all been led from primary care. However, despite that success, envied across the world, there remains a view that for the older person it is an unnecessary label against the natural process of ageing.
The labelling clearly has had a part to play but I would argue that having reduced glomerular function still provides additional risk. What we need to understand is that the risk is not just end stage renal disease (ESRD) and that competing risk may change as we age. So where is the evidence?
Two papers (Gansevoort et al Kidney Int 2011 and Hallan et al JAMA 2012) elegantly assess the complex area of risk for people with reduced GFR. Both conclude that the risk of ESRD is elevated in all age groups – that relative risk declines as we age, but the risk is still above the population norm. Therefore, there remains the need to identify people at risk of progressive renal decline.
The second risk is around increased cardiovascular event rate. Sadly, a 30 year old on dialysis has the same risk of a cardiovascular event as someone not on dialysis aged 85. The argument that nothing can be done is also incorrect. STENO 2 (Gæde et al NEJM 2008) looked at applying a package of care – lipid control, aspirin, ACE inhibitors and better diabetic control – to people with protein uric diabetic kidney disease. Mortality and cardiovascular events were halved over a decade.
The third cause of risk is that of acute kidney injury (AKI). Complicating the care of about 20 per cent of emergency admissions and responsible for about 40,000 excess deaths per annum (Kerr et al Nephrol Dial Transplant 2014), AKI is an important area for improvement.
We are now realising the bidirectional relationship between AKI and CKD. CKD itself is a potent risk factor for developing AKI (James et al Lancet 2010) but AKI itself may either result in CKD or progress CKD (Ishani et al Kidney Int 2009). So any strategy to improve AKI outcomes must include an awareness of the risk CKD brings.
So making my case, we have ample evidence that the awareness and management of CKD in primary care has resulted in benefit to individuals and to the system of healthcare. The competing risk of end stage renal failure, cardiovascular events and acute kidney may vary by age but the overall importance of CKD remains.
The role of primary care and of the CKD Quality of Outcomes framework has, and remains, vital components of that success. There remains a need to improve delivery and to ensure guidance is pragmatic but the pluses far outweigh any downside.
Current research has proven the benefit of early intervention in the primary care setting. As many of the people suffer from the diabetes and high blood pressure, which are their major kidney damage causes. Unless primary care suppliers distinguish these individuals as being in danger and begin dynamic administration, these patients might quietly advancement to having irreversible renal disappointment. So the patients don’t get any sign of kidney failure until they are damaged by more than 70% and so in this case the primary care takes intervene the person feeling unwell much before the stage of renal kidney failure.
Thanks Richard for this very informative article.
As a recently retired GP, I seem to have been one of the few that understood that what this really was about was preventing CVD. (From our perspective, as masses more of our patients die of CVD than end-stage renal failure.)
However, very rapidly the PC brigade took it over. So, whereas I was happy to say that an EGFR of 55 in an 87 year old didn’t mean much, some doctors who ought to have known better said, “No- to ignore that is ageism- you cannot except them from QoF” Cue the (in my view) inappropriate use of ACE-I and ARBs in lots of very elderly people, who now, if they get ill, or dehydrated, or both, end up with AKI and in hospital!