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Kidney disease's misleading label

A consensus conference finds it hard to agree on CKD with even its status as a 'disease' prompting fierce debate

By Daniel Cressey

A consensus conference finds it hard to agree on CKD with even its status as a 'disease' prompting fierce debate

The expert addressing the Edinburgh conference was a respected renal specialist, citing numerous references and speaking confidently and eloquently.

Which didn't stop an equally eminent professor seated nearby muttering 'rubbish!' at a key juncture.

Welcome to the UK consensus conference on chronic kidney disease – primary care's new bête noir.

In what might charitably be called a 'lively debate', assembled experts from hospitals, laboratories and general practice attempted to settle their differences over the importance of CKD and how it should be treated.

Even the matter of whether CKD deserved its tag as a disease was fiercely debated. The startling conclusion, a year after GPs were asked to take on a huge new CKD burden, is that in many patients it is not really a disease at all.

A new set of risk categories unveiled in Edinburgh suggests stratifying patients into those in need of CKD treatment, and those who have nothing more than an additional cardiovascular risk factor.

The stages sub-divide the current stage 3 – the bulk of primary care's share of CKD patients – into 3A and 3B. Stage 3A defines a lower risk group with eGFRs of 45 to 59; 3B a higher risk group with eGFRs of 30 to 44.

But even more important is a further stratification using the suffix 'P' for proteinuria – defined as protein:creatinine ratio greater than 100. Patients with only stage 3A CKD – who don't have proteinuria – need nothing more than standard cardiovascular risk management and an annual review of renal function.

Dr Kathryn Griffith, a GP member of the consensus group brought together by the Royal College of Physicians in Edinburgh and the Renal Association, says: 'A lot of patients in practices have CKD 3. There's a huge amount of work if we're to treat them all the same.'

Dr Griffith, a GP in York, believes the key point of the consensus statement is that CKD should be risk stratified using proteinuria testing – a point missing from the QOF.'

The most important thing the QOF should have is proteinuria for everyone. GPs haven't been doing it because they haven't been advised to.'

The Government's renal tsar, Dr Donal O'Donoghue, agrees there has been 'insufficient focus' on proteinuria.

Dr O'Donoghue, who is consultant renal physician at Salford Royal Hospitals Foundation Trust, says: 'Let's not forget there's a person who's been given the label of a disease when maybe what they have is a risk factor.

'Many patients with CKD don't need anything above what they should be getting for their diabetes or hypertension. I don't see that value is added by input of kidney specialists in all those instances.'

Referral guidelines

Also set out in the consensus statement are guidelines on who to refer – younger patients, those whose eGFR is falling by more than 4ml/min/year or with proteinuria.

But all this places patients with stable CKD firmly within the remit of primary care, including many of those with stage 4 disease.

'Many stage 4 patients are stable,' says Dr Lawrence Goldberg, principal lead consultant at the Sussex kidney unit in Brighton.

'Long-term GP care will need to be supported by specialists for things like anaemia, calcium, phosphate and parathyroid hormone. This could be in the community if adequately resourced.'

Some nephrology units have set up systems to allow patients to be managed at arm's length with support for GPs, who are unused to dealing with early CKD. Something they share, surprisingly, with nephrologists.

Dr John Main, consultant in nephrology at James Cook University Hospital in Middlesbrough, says: 'Until now kidney disease has been very rare – we were really only interested in severe disease. We're in this together – nephrologists have to become an education resource.

'Dr Main's unit has been running an e-mail advice line for local GPs. 'When we reply we try not to just say "do X" , but "do X because of such and such".'

Anecdotal evidence shows GP referrals have improved as they get used to this 'new disease'. Dr Goldberg says his hospital is seeing more new patients with CKD stages 4 and 5 and fewer with stages 1,2 and 3.

But while GPs may be starting to get on top of the CKD burden, there is still resentment at the way the quality indicators were introduced – and caution about primary care taking on even more work.

Dr Rod Combe, a GP and QOF assessor in Edinburgh, says: 'There's no doubt CKD 3 has created the biggest work increase.'

Dr Goldberg agrees: 'It was brought in too hastily. They should have let eGFR bed in.'

At root, though, doctors believe the statement is a leap forward. As Dr Main says: 'Two years ago nobody would have gone to a meeting on stage 3.'

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