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Targets for CKD in the QOF ‘could be unsafe’

By Nigel Praities

Chronic kidney disease targets in the quality and outcomes framework may be ‘unsafe' for some patients, GPs are being warned.

Experts urged GPs to exception report elderly patients without proteinuria whose blood pressure was well controlled.

They warned the requirement to treat all CKD patients with an ACE inhibitor or an ARB was frequently ‘inappropriate'.

The researchers analysed data from a general practice population of 9,021 patients.

Of 265 with a serum creatinine under 125µmol/l who were added to the CKD register, 86% were already on a cardiovascular register and 68% already controlled to the CKD target of 140/85mmHg.

The study concluded there was no justification for moving elderly patients to an ACE inhibitor if they did not have proteinuria and were already well controlled for blood pressure using treatments recommended by NICE. And it warned that adding in an ACE inhibitor or ARB raised the risk of hypotension.

Study leader Professor Mike Kirby, a GP in Radlett and professor of health and human sciences at the University of Hertfordshire, warned: ‘The current QOF guidelines may actually not be safe. For patients well controlled on a calcium channel blocker who are elderly and do not have proteinuria, it's not appropriate to change them to an ACE inhibitor. They may come to harm if they get dehydrated.'

GPs should exception report these patients for the ACE inhibitor requirement unless they had proteinuria, he said.

Dr Ahmet Fuat, a GP in Darlington and deputy chair of the Primary Care Cardiovascular Society, said the analysis revealed a mismatch between the QOF and good clinical practice. ‘Look at the patient, look at the risks and whether they have proteinuria or not and make a clinical decision, rather than blindly following QOF guidance to get more points,' he advised.

But Dr Gerald Partridge, a GP in Keighley and CHD lead at Airedale PCT, said he found the warning ‘surprising' and called for greater clarification for GPs on how to prescribe in this area.

The research was published in the latest issue of the British Journal of Cardiology.

Patients not suitable for ACE inhibitor or ARB treatment

• Patients with maximal hypertensive treatment, significant co-morbidities, obstructive uropathy or terminal illness
• Patients with specific contraindications such as renal stenosis, those at risk of hypotension, and those with previous adverse reactions
• Particular consideration should be given to elderly patients without proteinuria, and in whom the risk-benefit ratio is uncertain
Source: British Journal of Cardiology 2007;14:221-8

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