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Kidney disease in primare care: where are we now?

Karen Jenkins
RGN PGDip HE MSc
Consultant Nurse
Kent Kidney Care Centre
East Kent Hospitals University NHS Foundation Trust

Nicola Thomas
RGN BSc(Hons) MA PhD
Senior Lecturer in Renal Care
School of Community and Health Sciences
City University London

Recent initiatives in kidney care for primary care professionals, including both chronic kidney disease (CKD) and acute kidney injury (AKI) aim to improve consistency in practice across primary care

A number of important national initiatives concerning the care of people with chronic kidney disease (CKD) have been implemented in recent years. These include the publication of the National Service Framework for Renal Services in 2004/05, resulting in the reporting of estimated glomerular filtration rate (eGFR) alongside serum creatinine as a measure of kidney function from 2006.1

The Quality and Outcomes Framework (QOF) included a new domain for CKD in 2006, with amendments to the domain in 2008 and 2009. Finally, NICE guidance for CKD (Clinical Guideline 73) was published in 2008.2 These changes have been of great benefit to people with the condition, as those at risk are being identified much sooner than before and strategies to slow down the progression of the condition can be started much earlier.

However, it has become apparent that there is some inconsistency in practice across primary care. One of the main areas of concern is the variation in prevalence of CKD recorded by GP practices. In the UK it is not clear how many people in the UK have CKD stages 3-5, as data have not been routinely collected until recently.

Recent QOF data have shown an overall recorded prevalence of 4.1%. Although these data show that over 4% of adults in England are now recognised to have chronic kidney disease and are on primary care CKD registers, compared with some studies it may mean that around 50% of people with stage 3-5 kidney disease have not yet been identified as prevalence may be as much as 6-8%.3 The variance between practices in every primary care trust (PCT) remains high, so there is much work to do to ensure that people with this condition are identified and as a result, receive optimal care.

It is possible for practitioners to see how the prevalence of CKD recorded in their practice compares with local and national figures. Kidney disease profiles are available online (see Resources at the end of this article).

Policy initiatives
Kidney care networks are embedded or are emerging in all 10 strategic health authority (SHA) areas across England. They aim to support the commissioning and planning of high-quality kidney services. Tariffs for dialysis have been proposed and are due to be tested towards the end of the year. A great deal of controversy surrounds these tariffs as there are concerns that unrealistic pricing may affect quality of care. We wait with trepidation for the publication of the renal tariffs.

Quality standards for CKD are currently being developed by the National Institute for Health and Clinical Excellence (NICE) and are available for consultation. Recommendations from NICE CG39 (anaemia) and CG73 (CKD) have been developed into six quality statements by the Topic Expert Group.

Furthermore, eight draft quality statements from the UK Renal Association clinical practice guidelines (where the scope of the NICE guidance did not cover areas on the care pathway that the quality standard is to address) plus Department of Health publications were also considered in two of these statements.

A total of 14 draft quality statements have been presented for consultation (which ended 10 November 2010) and field testing, each with associated quality measures. The quality measures that accompany the quality standards aim to improve the structure, process and outcomes of health and social care. They are not a new set of targets or mandatory indicators for performance management. The anticipated date for publication is June 2011.

Anaemia management
Guidance on anaemia management in CKD (CG39), published in 2006, is currently undergoing a partial update, with new recommendations for the diagnostic evaluation and assessment of anaemia and the assessment and optimisation of erythropoiesis.4

At the time of publication of NICE CG39, guidance on limiting the upper level of Hb was primarily driven by health economics and a lack of evidence of additional benefit in patients treated to levels of Hb >12.5 g/dL. However, studies published in the literature since the guidance was released highlight a lack of benefit and possible harm related to higher Hb outcomes, dictating consideration of amendment to the published recommendations. The correction of anaemia to normal levels of Hb is not recommended in people with anaemia of CKD.
Many questions have been raised as to which levels of haemoglobin are acceptable and a new aspirational range of 10-12 g/dl is recommended. Symptoms and co-morbidities need to be taken into consideration, as do the treatments required to achieve the desired haemoglobin level. It is expected that the partial update will be published in early 2011.

Acute kidney injury
AKI, formally known as acute renal failure, is not a feature of the QOF but is of significant concern as it results in serious, life-threatening complications. The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report published in 2009 highlighted the process of care of patients who died in hospital with a primary diagnosis of AKI and took a critical look at areas where the care of patients might have been improved.5

The report found that 83% of patients whose deaths were investigated had suffered one or more complications of AKI. The most commonly occurring complications were found to be acidosis, hyperkalaemia and sepsis. A number of key recommendations included:

  • All patients admitted as an emergency, regardless of specialty, should have their electrolytes checked routinely on admission and appropriately thereafter.
  • All acute patients should have admission physiological observations performed and a written physiological monitoring plan made, taking into account the degree of illness and risk of deterioration, ie, early warning scores.
  • All acute admitting hospitals should have access to either on-site nephrologists or a dedicated nephrology service within reasonable distance of the admitting hospital.
  • All acute admitting hospitals should have access to a renal ultrasound scanning service 24 hours a day including the weekends and the ability to provide emergency relief of renal obstruction.

End-of-life care
Management of established kidney disease (ESKD) aims to provide the best outcome for the individual, depending on preference. The choices for those with ESKD include renal replacement therapy (RRT) in the form of haemodialysis, peritoneal dialysis, transplantation or not having RRT and treated conservatively. Those who have no wish for RRT continue to be managed by renal teams and are frequently managed at home with renal and community teams working closely together to support the patient's needs. In 2009 the End of Life Care for Advanced Kidney Disease: Framework for Implementation was published.6 Three test sites have been funded by NHS Kidney Care to develop and implement its recommendations and outcomes of these projects will be available at the beginning of 2012.

Finally, a very important to message to primary care practitioners is that chronic kidney disease is associated with increased cardiovascular risk. Many people with CKD also have hypertension, diabetes and other long-term conditions, such as heart failure. Joined-up care needs to be high on the political agenda and improved communication, patient-held records and collaborative working would undoubtedly improve standards of care for such patients. It also makes sense to have one set of blood tests/results that can be accessed by all those who are involved in the care of people with multiple long-term conditions.

References
Department of Health (DH). The National Service Framework for Renal Services. London: DH; 2004.
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.
National Institute for Health and Clinical Excellence (NICE). Early identification and management of chronic kidney disease in adults in primary and secondary care. NICE Clinical Guideline 73. London: NICE; 2008.
National Institute for Health and Clinical Excellence (NICE). Anaemia management in CKD. National clinical guideline for management in adults and children. Clinical Guideline 39. London: NICE; 2006.
National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Adding insult to injury: a review of the care of patients who died in hospital with a primary diagnosis of acute kidney injury (acute renal failure). London: NCEPOD; 2009.
NHS Kidney Care. End-of-life Care in Chronic Kidney Disease. Available from: www.kidneycare.nhs.uk/_Ourworkprogrammes-Conservativekidneycare-EndofLif...

Resources
Kidney Disease Profiles
W: www.kidneycare.nhs.uk/_Ourworkprogrammes-KidneyDiseaseinPrimaryCare-Chro...

A number of different initiatives have been developed to support primary care in becoming more confident in managing CKD. These include the development of an advanced online educational resource initiated by the CKD Forum of the British Renal Society
W: www.ckdonline.org

Patient information materials can be accessed on the British Renal Society website:
W: www.britishrenal.org/CKD-Forum.aspx

NHS Kidney Care has recently launched a document aimed at helping primary care professionals diagnose and treat patients with kidney disease in collaboration with those working in acute care. The resource includes a Facts and Figures handbook and a QOF toolkit. This is available on their website:
W: www.kidneycare.nhs.uk