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GPs facing tougher CKD workload

By Nigel Praities

GPs are to be asked to further ramp up their chronic kidney disease workload, with draft NICE guidance advising routine testing for proteinuria and stricter blood pressure targets.

The recommendations were earmarked for inclusion in the QOF before ministers rejected the proposed extra clinical points at the last minute in favour of measures on extending hours. Experts are now concerned the extra work will have to be undertaken by GPs without any additional resources.

The guidelines, which are currently undergoing consultation, suggest GPs should routinely carry out microalbuminuria testing in patients with CKD to quantify proteinuria.

GPs will be expected to treat patients with proteinuria with an ACE inhibitor or angiotensin receptor blocker, even when a patient does not have hypertension or cardiovascular disease. But NICE said there was ‘insufficient evidence' to recommend these drugs in CKD patients without proteinuria or diabetes.

This directly contradicts QOF guidance, but it is thought the GPC may move to address this.

The institute has set blood pressure ranges, rather than targets, of between 120mmHg and 140mmHg for systolic blood pressure and between 70mmHg and 90mmHg for diastolic blood pressure for patients with CKD.

The target ranges are tougher for those with proteinuria or diabetes.

Professor Mike Kirby, head of health and human sciences at the University of Hertfordshire and a GP in Radlett, said the focus on patients with proteinuria was ‘sensible'.

He added: ‘We know these patients are going to be at future risk of disease and also this will help to prevent progression of their kidney disease.'

Dr Kathryn Griffith, a GP in York and a member of the Department of Health's renal advisory group, also welcomed the guidance, but said she was concerned GPs would have to get used to another set of hypertension targets and adapt to routine urine testing for patients with CKD.

‘The big problem is that it is another test. eGFR was a new thing for general practice and this is another thing that is new.

‘We currently test microalbuminuria in diabetes, but there are not that many of those. But about 10% of the practice population have CKD and they will all need this new urine test,' she added.

Dr Griffith said she was disappointed proteinuria testing was not included in the QOF and as a result GPs would have no financial incentives to carry out the NICE recommendations.

‘The QOF has been left behind in everything. The Government is not interested in the QOF. The political driver is for access,' she said.

Professor Kirby agreed that the QOF had been left behind by NICE.

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