CKD targets drive mass overuse of ACE drugs
The GP contract is driving mass overuse of ACE inhibitors in patients with chronic kidney disease, the UK's leading renal experts warn.
A consensus statement from a panel of specialists, GPs and health economists questioned the evidence base used in developing CKD quality indicators.
The statement, drawn together by the Royal College of Physicians of Edinburgh and the Renal Association, calls for GPs to be paid to run dipstick tests on all patients with CKD – with only those with proteinuria requiring ACE inhibitors.
It urges GPs to exception report patients from the requirement for ACE inhibitors or ARBs if they do not have proteinuria and are controlled for blood pressure.
A series of experts warned the QOF was driving inappropriate use of medication in sometimes vulnerable patients.
Professor Bryan Williams, chair of the consensus panel and professor of medicine at the University of Leicester, said: 'In the absence of proteinuria we don't think the evidence is strong enough to use ACE inhibitors or ARBs.
'Many people over the age of 60 with hypertension would have some reduced eGFR – there's no evidence all those patients should be treated with an ACE.'
Dr Kathryn Griffith, a member of the consensus group and a GP in York, said the QOF had caused patients to be switched inappropriately.
'There's a lot of elderly people with minor degrees of abnormal renal function who don't have protein and there is no evidence they need their medication changing to an ACE or ARB.
'The important thing is this gives us a way to work out who needs attention – that's by testing for protein,' she said.
Professor Mike Kirby, professor in health and human sciences at the University of Hertfordshire and a GP in Letchworth, said at least a third of patients on his hypertension register had eGFRs of less than 60.
'We found we had a lot of patients who had eGFRs less than 60. I felt uneasy about switching them without good evidence.'
The statement also recommends not reporting eGFR values above 60 – in line with earlier suggestions reported by Pulse.
Professor Williams said: 'Patients with calculated eGFRs above 60 should not have the value reported, mainly because there's more inaccuracy. That's important as it's led to a lot of anxiety.'
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Panel's key recommendations
• Sub-classifying CKD stage 3 into two groups, 3A and 3B:
3A defines a lower risk group with eGFR of 45-59 ml/min/1.73m2
3B defines a higher-risk group with eGFR of 30-44
• Further stratification by proteinuria (PCR greater than 100)
• In the absence of proteinuria, it is acceptable for general practitioners to 'exemption code' patients from the requirement for ACEi/ARB prescription if blood pressure control is satisfactory
• No routine reporting of specific values when an eGFR is greater than 60
Specialists are formulating plans for three-quarters of patients with stage 4 chronic kidney disease to be managed in primary care.
They aim to shift even more CKD patients into the care of GPs to clear the decks for the surge of more advanced cases since introduction of eGFR.
A new study aimed to identify how many of stage 4 patients needed specialist care – and who could safely be discharged to GPs.
Only 27 cent of patients with stage 4 CKD – characterised by 'severely reduced' kidney function – required renal replacement therapy, with 70 per cent assessed as suitable for GP management.
The researchers found the factors predicting need for renal replacement were younger age, male sex, higher baseline proteinuria and diastolic blood pressure, lower baseline haemoglobin and eGFR and more rapid kidney deterioration.
Study author Dr John Harty, consultant in nephrology at Daisy Hill Hospital in County Down, Northern Ireland, said: 'We've realised patients with just stage 4, who don't have large amounts of proteinuria or renal decline and have well-
controlled blood pressure, can quite safely and appropriately be managed in primary care.
'I would say at least 60 per cent, probably 70 per cent, could be discharged, but it's not a closed door – the caveat is there is easy and rapid access to secondary care.'
The study, presented at a conference in Edinburgh last week, tracked 424 patients with stage 4 CKD for five years.