Table 1.

Issues for primary care in the management of people with chronic kidney disease (CKD).

Index of main themes	Index of subthemes derived from the focus group discussions
(A) General responses to the response to renal disease	National CKD guidelines have led to a more active and systematic introduction of national guidelines. Classifying patients by CKD stages takes away from whole patient assessment. Guidelines have not changed the management of stable (CKD stage 3) older patients. The use of the protocol ‘suddenly flooded’ the practice with ‘new’ CKD patients, and led to an increase in the number of patient consultations and thus increased staff workload. CKD QOF acts as the prompt within the practice to identify potential CKD patients.
(B) Issues surrounding use of the eGFR measure	Helpful in making CKD diagnosis as it is easier to monitor and assess the rate of renal decline. The sensitivity of the eGFR has raised awareness about when to refer; before the test it was only patients with deteriorating creatinine levels who were referred on. National guidelines did not warn that non-fasting tests can produce false-positive measurements of eGFR. eGFR readings in the same patient can be volatile over time and are also not a valid measure in the over 75s.
(C) Labelling issues: kidney disease part of the normal ageing process	The label ‘chronic kidney disease’ can induce fear and is stigmatising for patients. CKD is a new label/reclassification of a pre-existing disease condition — not the identification of a new disease. A low eGFR level/declining renal function is normal for older people. CKD is a diagnostic label based on a test of renal function rather than of a discrete pathology. It is necessary to refine the CKD label as patients typically do not have ‘isolated CKD’ but have other comorbidities.
(D) Issues surrounding the giving of a CKD diagnosis	Informing patients they have been classified CKD stage 3 unduly raises patient anxiety — some think they require kidney transplant. The term kidney ‘impairment’ is used at eGFR <60 (mL/min/1.73 m2) mark rather than CKD — to downplay the impact of a CKD diagnosis. GPs should not put a CKD 3 diagnosis on a patient's record without informing them — medical-legal requirement. The practice does not automatically tell patients that they have been put on the CKD register. There is not adequate time in a 10-minute consultation to explain to patients the significance of the eGFR score.
(E) Issues surrounding the management of blood pressure in CKD	There are no obvious benefits of more closely managing blood pressure in CKD as patients in this group typically have many other chronic problems. Benefits of controlling blood pressure in patients with deteriorating renal function will be a reduction in coronary heart disease risk. There are difficulties associated with meeting the QOF blood pressure guidance for many older patients because of their tolerance of antihypertensive medication. Achieving patient compliance with a blood pressure management protocol requires time-consuming explanations and additional support. Patients are increasingly aware of side-effects of antihypertensives so less compliant, thus there are difficulties in meeting target reductions. The decision to prescribe antihypertensives to older patients cannot be made on the basis of any single measure of renal function. There are questions surrounding the reliability of home monitoring of blood pressure, and therefore the efficacy of using these data in patient management.
F) Patient self-management and compliance issues in relation to meeting blood pressure targets	Home monitoring of blood pressure is encouraged by the practice as it avoids the anxiety of having it taken by professionals. Meeting blood pressure targets for CKD patients is dependent upon their compliance with the additional medication required. Medication alone is not enough to meet blood pressure targets; patients themselves have to be willing to change lifestyles. Some patients prefer to live with high blood pressure than to take medication because once on it, they are on it forever.
(G) Referral issues	Referral to secondary care should only be for CKD 5; no automatic referral is necessary for CKD 3 and 4 if blood pressure is controlled. All patients with CKD stages 4 and 5 are referred for secondary care. For CKD, like all chronic conditions, it is important to know when it is appropriate to refer to secondary care — here national guidelines have been very useful. The practice has received generally good CKD patient support from the local hospital nephrology clinic.
(H) Educational requirements of practice regarding CKD	There is a need to develop internal expertise among one or more GPs in the practice — no necessity for referral for most with CKD. Never learnt about CKD in medical school — didn't know how to manage it when starting in general practice. Practice produces its own one-page protocol based on national and local guidance. Practice is not familiar with national guidance — QOF is taken as basic guidance for managing CKD.