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Recognising early signs of chronic kidney disease

Recognising early signs of chronic kidney disease

Chronic kidney disease (CKD) affects between 6% and 7% of the population.1 CKD is an important risk factor for both end-stage renal disease and for cardiovascular disease (CVD), with which it frequently co-exists. However it is often unrecognised since it causes no symptoms in the early stages. Early identification of CKD in primary care is therefore beneficial especially as there is evidence that early treatment can improve outcomes.


However quality and outcomes framework (QOF) data indicates that there is widespread variation in the identification and treatment of kidney disease in primary care. The overall recorded prevalence of CKD in England in 2010/2011 was 4.3%,2 yet there was wide variation across England with some practices recording less than 1%. In addition, many people with a coded CKD diagnosis are not informed of it,3 yet we know from studies in patients with more advanced CKD that they express a strong desire to be actively involved in the management of their condition with their clinicians.4 The early identification and treatment of CKD is therefore recognised as a major public health issue and a target for improvement.

Risk factors for CKD
The staging of CKD is now recognised internationally and is based on the Kidney Disease Outcome Quality Initiative (KDOQI) study.5 The focus of this paper is CKD stages 3–5, defined as GFR <60 ml/min/1.73 m2 for at least three months. CKD usually progresses slowly and gets worse over time, often over many years. Symptoms may not appear until kidney function is 10%-15% of what is considered normal, so identification of risk factors is very important. People at most risk of CKD are those with diabetes and/or hypertension. Diabetes and hypertension are the two most common causes of CKD. Diabetes can substantially increase the risk of developing moderate to severe CKD (stages 3b, 4 and 5): in women the risk is about eight times higher and in men over 12 times.6 In the UK, diabetes accounts for 24% of all new patients starting renal replacement therapy.7

Other diseases and conditions which can damage the kidneys, include:
    - Glomerulonephritis.
    - Autoimmune disorders (such as systemic lupus erythematosus).
    - Renovascular disease.
    - Genetic disorders (eg, polycystic kidney disease).
    - Kidney stones and infection.
    - Neprotoxic drugs.


The chance of developing CKD increases with age, and people of African-Caribbean or south Asian ethnic groups are more likely to develop kidney disease. CKD also appears to progress more rapidly in patients from lower socio-economic groups.8


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 (see Resources).

Testing for CKD
Everyone at high risk should have an annual blood test (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 in the Resources section.


There is evidence that some primary care practitioners are anxious about disclosure of early stage CKD with patients. A qualitative study undertaken in general practice identified that anxieties were often related to identifying and discussing CKD in older people and patients with stage 3A.4 Discussing the diagnosis of CKD is very important as it provides an opportunity to discuss lifestyle choices, address cardiovascular risk factors and also medicine management. In addition, CKD is a risk factor for acute kidney injury, which complicates as many as one in five of acute admissions to hospital and is associated with poor outcome.9

Early signs and symptoms
It is important to explain to patients that they will usually not experience any signs or symptoms of early kidney damage (during stages 1-3), but once they reach stage 4 CKD then they may experience one or more of the following:
    - Producing more or less urine than usual.
    - Fatigue or feeling more tired than normal.
    - Loss of appetite.
    - Itchy skin.
    - Signs of fluid imbalance such as ankle swelling or shortness of breath.

Slowing progression
Controlling blood pressure will slow deterioration of kidney function. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are anti-hypertensive agents of choice.


The goal is to keep blood pressure below 140/90 mmHg (or 130/80 mmHg for those with diabetes and/or proteinuria).10 However there may be up to 30,000 people with CKD who could benefit from ACE/ARBs and are not currently receiving them.11 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,11 timely prescription of anti-hypertensive therapy is crucial.


Other advice for patients to help protect the kidneys and prevent CVD includes:
    - Smoking cessation.
    - Avoiding nephrotoxic medication, especially non-steroidal anti-inflammatory drugs (NSAIDs).
    - A diet that is low in fat and salt.
    - Regular exercise.

Resources for practitioners and patients
A ‘Package of Innovation’ for managing kidney disease in primary care has been developed by a team of practitioners and people with experiences of kidney disease and other long-term conditions. The resources are based on those that were used in the ENABLE-CKD quality improvement project, carried out in 26 GP practices in England and Wales during 2010-2012, funded by The Health Foundation and managed by Kidney Research UK. See www.kidneyresearchuk.org/enable for more information on this project.
The innovation package contains a variety of resources including a training package about kidney disease and self-management including a slide set, teaching notes, a comprehensive information booklet to help people to look after their kidneys together with an educational DVD. Details are available on the research pages at www.kidneyresearchuk.org or by emailing kidneyhealth@kidneyresearchuk.org.

Conclusion
Although early signs of CKD do not show themselves in terms of signs and symptoms, stage 3A kidney disease can be identified through annual blood tests that measure eGFR and annual urine tests for proteinuria. Primary care nurses should take every opportunity to discuss the implications of having CKD with their patients, as early intervention can improve understanding and self-management, prevent deterioration and be cost-effective.

Resources
NHS Choices Kidney Disease Checker
www.nhs.uk/tools/pages/kidneydisease.aspx
Thomas N. Timetable of Tests for Chronic Kidney Disease. British Journal of Primary Care Nursing 2009;6(2)18-9.
Available at: www.bjpcn-cardiovascular.com/download/3329

References
1.     de Lusignan S, Chan T, Gallagher H, et al. Chronic kidney disease (CKD) management in southeast England: a preliminary crosssectional report from the QICKD – Quality Improvement in Chronic Kidney Disease study. Primary Care Cardiovascular Journal 2009;2(Special issue CKD):33-9.
2.     NHS Information Centre. QOF Prevalence data tables 2010/2011. Available at: www.ic.nhs.uk/statistics-and-data-collections/supporting-information/aud....
3.     NHS Information Centre. Health Survey for England: Health and Lifestyles. London: NHS; 2009.
4.     Blakeman T, Protheroe J, Chew-Graham C, Rogers A, Kennedy A. Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study. Br J Gen Pract 2012;62(597):
e233-42.
5.     Levey A, Coresh J, Greene T, et al. Chronic Kidney Disease Epidemiology Collaboration. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Internal Med 2006;145(4):247-54.
6.     Hippisley-Cox J, Coupland C. Predicting the risk of Chronic Kidney Disease in Men and Women in England and Wales: prospective derivation and external validation of the QKidney® Scores. BMC Family Practice 2010;11(49).
7.     UK Renal Registry. The Fourteenth Annual Report of the UK Renal Registry. Bristol: UKRR; 2011.
8.     Shoham D, Vupputuri S, Kshirsagar A. Chronic kidney disease and life course socioeconomic status: a review. Advances in Chronic Kidney Disease 2005;12(1):56-63.
9.     Abdi Z, Gallagher H, O’Donoghue D. Telling the truth: why disclosure matters in chronic kidney disease. Br J Gen Pract 2012;62(597):172-3.
10.     National Institute for Health and Clinical Excellence. Early identification and management of chronic kidney disease in adults in primary and secondary care. NICE clinical guideline 73 2008.
11.     Kerr M. Chronic Kidney Disease in England: The Human and Financial Cost. London: NHS Kidney Care; 2012.


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