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The waiting game

GPs urged to do ACR testing for patients at risk of kidney disease

Renal experts are urging GPs to carry out NICE-recommended urinary ACR tests in patients with a high risk of kidney disease, after an audit revealed many patients in risk groups had not been tested.

The national audit looked at data from 911 GP practices in England and Wales and found that, whereas nearly nine out of ten patients with diabetes had the recommended eGFR tests done annually, only half had their urine ACR (albumin-to-creatinine ratio) checked every year as advised by NICE.

For other groups at risk of chronic kidney disease (CKD) – such as people with hypertension, cardiovascular disease, or family history of kidney disease – less than a third received the appropriate ACR testing.

The audit report also called for GPs to improve on the accuracy of coding of CKD, after finding huge variation among practices – the proportion uncoded ranged from zero to 80%. Overall, 70% of people with confirmed CKD had an appropriate Read code, while 65% of those with a CKD Read code had the eGFR test results to support the diagnosis, the report found.

NICE brought in urine ACR testing in 2014, to help classify risk levels in people with impaired renal function, and advised that people with diabetes have both their eGFR and urine ACR tested annually, while other groups with increased risk of kidney disease, such as those with hypertension, should have both tests done on a five-yearly basis.  

It subsequently emerged GPs in parts of Wales were unable to order the ACR tests in line with the NICE guidance, at least for some ‘at-risk’ groups of patients. 

But Dr Kathryn Griffith, RCGP clinical champion for CKD and a member of the audit board, told Pulse the test was widely available in most areas.

Dr Griffith said: ‘It is available and it is not a particularly expensive test – the issue is people aren’t doing it, because patients don’t like urine testing. But it is more helpful than eGFR testing.’

She stressed that measuring ACR ‘helps you to have a full picture – the person’s ACR, eGFR, their age, their underlying diagnosis, all of these are important to get a full picture of the patient and their risk’.

Dr Griffith added: ‘The pressure for avoiding overdiagnosis and overtreatment has swamped the idea we should be diagnosing CKD properly. If you have an elderly person with a moderately reduced eGFR who is not taking any risky tablets then, ok, you don’t need to worry too much about them.

‘But younger people with high levels of ACR, who are on an ACE inhibitor, they are as at risk of acute kidney injury as an older person.’

The audit was commissioned by the Healthcare Quality Improvement Partnership and carried out by Informatica systems in collaboration with London School of Hygiene and Tropical Medicine, University College London and Queen Mary University of London. 


Readers' comments (4)

  • "Many patients IN RISK GROUPS have not been tested"
    Many patient with active current illnesses are struggling to get appointments.
    Look out the window of your ivory tower, we don't have the resources to find and treat every bit of pathology out there!

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  • Dear NICE, renal experts, clinical champions, ad- nauseum,

    If you think its so easy to take the piss out of patients then we invite you to have a go and show us how you can do it better. After all you most clearly have the time....

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  • David Banner

    The amount of time and effort in performing ACRs on ALL diabetics is enormous. The pots, the sample tubes, the forms, the repeat form(s) when the patient fails to produce, the urine sloshing around everywhere.....then repeat EVERY year?
    Once microalbumiurea and/or CKD3-5 has been confirmed, and BP target achieved with ACE, what's the point? And the age 80plus? And the patient with 10 normal ACRs in 10 years?
    One size does not fit all, testing every patient every year is too onerous, which leads to poor uptake, meaning high risk patients are missed. Targeted testing will yield far better results.

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  • What is the NNT until we find 1 patient with proteinuria?.

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