Managing chronic kidney disease

By raising the subject of the role of primary care in managing chronic kidney disease, Brady and O'Donoghue may have sparked a timely debate.¹ It would also be good to hear from primary care physicians on this issue.

While they call for primary care to take ownership of the problem, it seems clear that colleagues I have spoken to are mystified and confused. Here is a new disease that apparently one in 10 people have, no longer the rare condition we were brought up with as students, and that clever kidney doctors managed with strange diets, pills, potions, and transfusions (not quite leeches). Little wonder we, as GPs, have been frightened off from believing we had a role, especially as the patients don't complain of anything. So now we have a role, what should it be? I believe it turns out to be rather easier than we imagine.

First, find the patients. We're doing the bloods anyway. They nearly all fall into just four categories.

These are people with diabetes, hypertension, older people, and then people with intrinsic kidney disease. The latter is for the clever kidney doctors and can be found because they have rapidly deteriorating kidney function and/or heavy proteinuria or blood, or a family history of polycystic kidneys.

The rest are for us to manage. We find them by looking for them in our populations with diabetes and hypertension. The older population with ageing kidneys will declare themselves along the way with high blood pressure. If these older people don't have high blood pressure there's nothing for us to do apart from give usual healthy living advice.

Once identified we need to treat their vascular risk factors, especially lifestyle and hypertension. Get their blood pressure to target levels of <140/90 mmHg, and if they have significant proteinuria, use ACE inhibitors or ARBs and aim for <130/80 mmHg. I have a low threshold for adding statins although the jury is still out about how effective they are in more severe renal impairment.² One meta-analysis showed benefit in all cause mortality, CVD mortality, non-fatal CVD events, and a reduction in 24-hour urinary protein excretion.³ We don't need to worry about bicarbonates and bone disease at the stage we are dealing with, unless something crops up in our routine blood tests.

To keep the critics of primary care at bay, make sure patients records are Read Coded correctly, and the QOF will do the rest in terms of auditing the population.

Primary care is getting there but the mystique of CKD has to be removed. This will come with time and education.