Primary Care UK: Let's Learn Together
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Primary Care UK: Let's Learn Together
Managing Chronic Kidney Disease in Primary Care: Essential Insights
IN THIS EPISODE, doctors Catherine Byrne and Rahul Mohan discuss the critical aspects of managing chronic kidney disease (CKD) in primary care. They explain: the definition, prevalence, and risk factors of CKD, highlighting its association with other conditions such as hypertension, diabetes, and cardiovascular diseases.
Led by podcast host Irina Varlan, the conversation covers the role of primary care in early detection, optimal management, and timely referral to secondary care. They also discuss the importance of lifestyle modifications and the advancements in CKD treatments, including the adoption of new medications like SGLT2 inhibitors and finerenone. The discussion emphasizes the need for accurate coding and record-keeping in primary care to ensure effective monitoring and improved patient outcomes. Finally, the episode provides insights into various resources available for patients to help them understand and manage their condition better.
SPECIAL THANKS TO GUEST SPEAKERS:
Catherine Byrne, kidney consultant in Nottingham City Hospital. CKD Midlands Renal Network Lead
Rahul Mohan, GP in Rushcliffe and GPwER in Diabetes and CVRM Medicine, Nottingham and Nottinghamshire ICB. Board member, national Executive Committee of Primary Care Diabetes Society and SAHF.
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USEFUL RESOURCES:
CKS link-https://cks.nice.org.uk/topics/chronic-kidney-disease/
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CKD FOR PRIMARY CARE.
THIS TRANSCRIPT IS AI GENERATED AND WILL CONTAIN ERRORS!
[00:00:06] Munir Adam: Welcome back. It costs 1. 45, that's nearly one and a half billion pounds, and leads to 45, 000 or so premature deaths each year. What are we talking about? Of course, we're talking about chronic kidney disease. What else did I learn? Well, I learned that it's actually the 10th biggest killer worldwide. Did you know that?
[00:00:27] Well, anyway, somebody gets diagnosed with this. Who are the ones who are going to have trouble afterwards? Have you heard of the KFRE risk score? And now here's another question for you. What is the single most significant prognostic marker of deterioration for those who have been diagnosed with chronic kidney disease?
[00:00:46] I didn't know the answer, but keep listening and you will get the answer to that question and many others. in relation to this really important condition that, let's face it, we haven't been giving it the importance and attention that it deserves for a long time. But thankfully, there are some out there who are very much dedicated to this, and we'll be hearing from two people who are very much into this, as they are going to be having a conversation with Irina Valin. Who, as you will know from some previous episodes, is a pharmacist representative of our Primary Care UK team in Nottingham.
[00:01:18] The simple point here is that there is much more we can be doing, should be doing, because this condition is significantly under diagnosed. And as you listen to this, I'd ask you to consider, what is it that you could be doing differently to help improve people's lives?
[00:01:32] Perhaps in diagnosis, perhaps in terms of improving their prognosis, maybe referring at the most appropriate time. It's Munir Adam here. Welcome back to Primary Care UK. Let's learn together, the podcast for all the frontline clinicians working in primary care. And I'll now hand you over to Irina.
Introduction and Guest Introductions
[00:01:49]
[00:02:03] Irina Varlan: Hello and welcome. Thank you both for accepting my invitation to have a discussion about chronic kidney disease in primary care. Before we start, could you
[00:02:11] Catherine Byrne: please introduce yourselves? Hi, yeah, I'm Catherine Byrne. I'm a kidney consultant in Nottingham City Hospital and I'm also the CKD Midlands Renal Network lead.
[00:02:23] Rahul Mohan: Hi, I'm Dr. Rahul Mohan. I'm a GP and also a GP with an extended role in diabetes and cardiovascular renal medicine.
[00:02:33] Irina Varlan: Thank you both.
Understanding Chronic Kidney Disease (CKD)
[00:02:34] Irina Varlan: Can we start by covering briefly what is chronic kidney disease and who gets it? Thank you. Is CKDH specific? Can anyone get it?
[00:02:44] Catherine Byrne: Thanks, Irina. Chronic kidney disease is defined as having a decline or a decreasing kidney function.
[00:02:51] So this would be an estimated GFR of less than 60 on two readings persisting for three months. Or it could be that you find kidney damage, for example, abnormalities on a scan, such as polycystic kidneys or small scarred kidneys. or it could be the presence of blood and or protein in the urine that's not associated with a urinary tract infection and their ACR is over three milligrams per millimole.
[00:03:21] It could also be something that you find once you've taken a biopsy of someone's kidney. We know it's very common. It is likely to affect one in seven or eight people in the UK and in some people it will lead to a progressive loss of kidney function, ultimately resulting in the need for kidney replacement therapy, be that dialysis or transplantation.
[00:03:42] But I think the thing about chronic kidney disease that we're understanding more and more is that we should really be considering this as a long term condition and in particular part of a cardiometabolic renal syndrome. Most of our patients with chronic kidney disease also have other disease conditions.
[00:04:01] So 95 percent of patients with CKD are likely to be on a hypertension or a cardiovascular disease or a diabetes register. It's an independent risk factor, however, for developing cardiovascular disease, and it's much more common as patients age. So many of our patients will ultimately be picked up coincidentally because they present with another disease condition and they're often multi morbid.
[00:04:28] It should also be recognized that whilst chronic kidney disease is very common, Many of our patients actually are likely to die before they ever need kidney replacement therapy.
[00:04:40] Rahul Mohan: Thanks Kat.
Risk Factors and Screening for CKD
[00:04:40] Rahul Mohan: And I think that very nicely brings me to one of the commonly used resource is the nice clinical knowledge summaries that recommends screening for all those at high risk of chronic kidney disease.
[00:04:55] And, and what are the risk factors for chronic kidney disease? They are diabetes, a new diagnosis of hypertension, patients who are having acute kidney injury or AKI, patients with cardiovascular disease, also patients with structural renal tract diseases, like patients who have kidney stones, those who have multi system diseases that may involve the kidney, for example, SLE, myeloma, and those also with the family history of CKD5 or head kidney disease like the adult polycystic kidney disease.
[00:05:29] One should also be looking out for where there is an opportunistic detection of the hematuria or the proteinuria. Another important group of patients are the gout patients. We should also pay attention to the urinary sediment abnormalities, such as the red blood cells, which might indicate a glomerular disease, white blood cells, which may indicate a heart disease.
[00:05:52] pylonephritis or interstitial nephritis, but I think one should also be aware of that the disease may often be asymptomatic in the early stages.
[00:06:03] Catherine Byrne: I see.
Impact and Burden of CKD
[00:06:04] Catherine Byrne: In terms of a better understanding hopefully that people have about chronic kidney disease, I think it's come to the forefront in everybody's minds more recently because the hot topics have risen because we now seem to have a plethora of new drugs that have come to market that You can potentially help our patients with chronic kidney disease, both in terms of improving the quantity as well as their quality of life.
[00:06:30] And chronic kidney disease is a huge health burden to our population. It's estimated that the annual cost to the NHS is around 1. 45 billion pounds and it causes around 45, 000 premature deaths each year. CKD is also associated with more than 100, 000 hospitalisation events, and we know that in those patients who are hospitalised who have CKD, they stay on average 35 percent longer than those patients without CKD.
[00:07:02] As patients and the general population are living longer and life expectancy has increased, unfortunately, because of lifestyle choices, male people have developed diabetes, they Obesity is on the rise. So hypertension is becoming more common. And as we've alluded to, these are all risk factors for developing chronic kidney disease.
[00:07:23] So we're going to talk hopefully a bit about some of these drugs that have come to market that can hopefully help reduce the risk of declining kidney function and prevent our patients from reaching a point where they'd need to consider dialysis. And I think as we've added years to our lives, it's really important we now try and add quality to those years.
[00:07:46] Irina Varlan: Thank you both for explaining all that.
Prevalence and Data on CKD
[00:07:48] Irina Varlan: And do we have any data to tell us what's the prevalence of UK? Is there like a national audit?
[00:07:56] Rahul Mohan: Yeah, and I think this is a very good question. KD is a common condition. The incidence and the prevalence vary depending upon the population which is being studied, including the ethnic group and the socioeconomic class.
[00:08:09] There is an estimated global prevalence of around 9. 1%. with diabetes mellitus accounting for 30 to 50 percent of these cases and closer to home in UK, we have over 1. 9 million adults who have been diagnosed with CKD, although we must accept that there are many more who remain undiagnosed. The prevalence is expected to continue to increase due to an aging population and a higher incidence of the diseases as like type 2 diabetes and hypertension.
[00:08:42] Catherine Byrne: If you look at CKD prevalence, It depends really on what source of data you use, whether you use QOF or CVD Prevent. QOF only asks primary care to record CKD patients G3 to 5 and G1 and 2 are not required to go on a CKD register. This is likely an underestimate. If you look at CVD Prevent data in England, it's 3.
[00:09:08] 9%. We are trying to look at data nationally in the UK. And the UK Renal Registry is looking at collecting data, but this is only from secondary care kidney units across the UK. And it's looking at patients who we see who may be progressing towards dialysis or the need for a transplantation and looking at advanced kidney care.
[00:09:33] But I think The big issue we have is, are there people who are known unknowns that aren't being registered as having CKD out in primary care, so for example that's the people with stages G1 and G2 who are not on a register but may be known to primary care. But there's also the unknown unknowns, so from CBD Prevent, looking more widely at the Midlands in general, we know that around 50, 000 people.
[00:10:02] who are adults with an EGFR less than 60 on two consecutive occasions have not been coded. So we know that we are missing people and the question really is how many?
[00:10:13] Irina Varlan: I see. Thank you both.
Diagnosing CKD in Primary Care
[00:10:14] Irina Varlan: And how can you tell somebody has CKD? You've mentioned earlier, Rahul, that the early stages you could go asymptomatic.
[00:10:21] Do we screen for it in primary care? I mean, I suppose people already diagnosed with diabetes or cardiovascular disease, they have regular. blood tests, but if you don't have another diagnosis, how do you detect CKD?
[00:10:34] Rahul Mohan: Yeah, no, I think this is something we are quite good at picking up diabetes, but we are not good at picking up the CKD.
[00:10:42] With regards to the diabetes, in the diabetes care, we do the urine sample. There is some lack of compliance among the patients in bringing back the urine. the sample, but something which I say to my colleagues is that it is better to deal with a leaky kidney than to be left with a failing kidney. And one has to also understand is that the patients who have a diagnosis of diabetes or cardiovascular disease do get their EGFR tested quite regularly.
[00:11:10] But if they don't have another diagnosis, the question can be that can we detect the early CKD and that has not been addressed.
[00:11:18] Catherine Byrne: Thanks Ro. I mean, thank you. Early stages can be, and they usually are, asymptomatic. Most patients only really start to get symptoms once their GFR is less than 25, and in some cases it can be when GFRs are significantly lower than that.
[00:11:32] If they are going to get symptoms, they tend to be quite non specific, so it's particularly feeling fatigued, you may feel sick. retching and or vomiting but usually that's at quite late stages. Some people may be itchy or breathless. Some people, particularly people with diabetes, may show signs of ankle swelling or fluid overload and they may have altered taste and subsequently a loss of appetite.
[00:11:57] But in terms of trying to detect it, I think the opportunity really is because we've alluded to the fact that 95 percent of patients with kidney disease also have another associated condition like diabetes, cardiovascular disease or hypertension. I think there's lots of opportunities to detect CKD at that stage.
[00:12:19] And as Rahul alluded to, I think it's really important that we ensure people have a urinary ACR check, particularly in those at risk groups. And I think it's trying to make the most of those opportunities in terms of ensuring that there is. blood pressure, you're in ACR and kidney function monitoring.
[00:12:38] Irina Varlan: Right, so just for myself, CKD.
Managing CKD: Early Detection and Monitoring
[00:12:42] Irina Varlan: can be diagnosed in primary care. Yeah. Or do you need any secondary care input?
[00:12:47] Rahul Mohan: Yeah, no, I think most of the people should be diagnosed in primary care because if it is being diagnosed in secondary care, it is normally because there has been a missed opportunity in primary care.
[00:12:58] I must highlight that there is a CQC criteria that one has to really also adhere to is that if there are two EGFRs less than 60, three months apart, then they should be. coded as chronic kidney disease in their electronic health registers. If the patient has a unary ACR above 30, that means that the patient is having a kidney disease even if your EGFR value is above 60.
[00:13:26] So a high, urinary ACR might be an early sign of kidney disease, but your healthcare system team will check that to make sure that this albuminuria has not been caused by something else. We in primary care are also guided by what are quality and outcomes framework the cough involves and the cough points for the CKD is unfortunately is just for maintaining a CKD register.
[00:13:56] I think it is really quite important that the patients should have a read code of CKD on their electronic health records because it does allow them being recall and monitor. But The ground reality is that unfortunately the urinary ACR is no longer the part of the cough since 2014 and the rates have been falling since then and COVID 19 pandemic didn't help the matters either.
[00:14:24] So I think what we would hope for is that these testing rates should improve. Locally, we do not have any local enhanced service related to CKD. Yes, we have some good examples in the region where Birmingham and Solihull ICB have done an enhanced service for the hypertension. And as a part of that, they have included the Unani
[00:14:50] Catherine Byrne: ACR.
[00:14:50] Um, yeah, thanks. I think really you've got to be in it to win it, so to speak. So unless, you know, you've got CKD. and you've been labelled as such in your healthcare record in the community, then you're not going to get a recall in order to optimise your care, monitor you adequately and appropriately and as frequently as is required.
[00:15:12] We know CKD is currently the 10th biggest killer worldwide and it's predicted to be the fifth leading cause of lost life years by 2040, which is literally less than 20 years away. We've got some very old data pertaining to how expensive care is, and I alluded to that at the start of the podcast, but in 2009, it cost the NHS 50 million pounds a year just for the transport costs for patients.
[00:15:38] To and from the hospital for haemodialysis and dialysis cost five hundred and five million pounds a year I mean that's 15 years ago So you can imagine what the costs are going to be like in today's current times And so it's really important that not only from a financial perspective But also from a quality of life perspective that we diagnose people early So that we can optimise their care, try and maintain a good quality of life for these patients, as well as life years.
[00:16:10] We've mentioned CKD's not really been in as much focus in the past as other disease processes. It doesn't seem to receive as much funding or as attention, it's not as a motive. But we've got lots of opportunities because I think what we're trying to say to people is consider this a long term condition.
[00:16:29] Consider this as part of a cardiometabolic renal syndrome. There's plenty of opportunities for patients to be reviewed as part of a primary care long term condition clinic. And I think it's really important that if we optimize care, we can improve survival rates. And really this is about prevention and risk reduction.
[00:16:52] Irina Varlan: Thank you. It's really interesting. The implications of a positive diagnosis are perhaps not always clear. If we do diagnose early, what can we do about it?
Optimizing CKD Treatment and Medication
[00:17:03] Irina Varlan: Can we delay the progression of CKD?
[00:17:06] Catherine Byrne: It's important to diagnose early in order to be able to optimize care and ensure adequate monitoring. So we've mentioned that most of the time people are asymptomatic but at the same time they've got lots of other comorbid conditions.
[00:17:22] If you go back to the start, a lot of this is public health work. It's about lifestyle. What you want to do is prevent people developing diabetes, try and reduce the number of people who are smoking that will reduce their risk of cardiovascular disease, reduce obesity. This will help with blood pressure and diabetes rates.
[00:17:43] So there's lots of things we can do from a perspective. But then for those who have got CKD, it's about optimizing their medications really. We've got tools that will help identify those who are at greatest risk, so prognostication tools. So the one that NICE has included in their NICE guidance is the kidney failure risk equation or KFRE for short, and that uses the four variables of age, gender, urine albumin creatinine ratio or ACR and EGFR.
[00:18:20] in people with CKD. So you've got to have a GFR of less than 60 to use this prediction tool. And it will give you a two and a five year risk of needing dialysis or a kidney transplant. There are caveats with it. It does not take into account your morbidity. So your other health conditions or indeed how that impacts on your risk of death.
[00:18:45] So there was a paper looking at CD predict from January this year in the BMJ and that is something we should be using alongside kidney failure risk scores because that will look at someone's risk of death versus with the care for someone's risk of needing dialysis or a transplant. In terms of other tools we have available, I think The one thing that we really need to know is their urine ACR.
[00:19:16] And that's because urine albuminuria is the single most important prognostic marker for who is going to have a decline in their kidney function. So if you've got a urine ACR, A, you need it to do the kidney failure risk equation score. But B, it will help identify those who need prompt referral to secondary care.
[00:19:38] Rahul Mohan: Yeah. So I think what we have to do in primary care, and I think here the nice clinical knowledge summary has clearly given us some guidelines that once the patient has a confirmed diagnosis of chronic kidney disease, we have to agree on the frequency of the monitoring with them and then arrange the specialist referral if it is appropriate.
[00:19:59] We also have to identify what are the underlying causes and the risk factors which are associated for disease progression. Because that is what is going to also influence the frequency of monitoring. Something which we in primary care should also be aware about is the accelerated progression and the accelerated progression is defined as having a sustained decrease in the EGFR of 25 percent or more or a change in the CKD category within the last 12 months or it can also include patients who are having a sustained decrease in the EGFR of 15 mils within the last 12 months.
[00:20:45] Uh, we should also be aware of that the small fluctuations in the EGFR and ACRs do not necessarily indicate a disease progression. So it's important that in order to assess the rate of progression, we have to be repeating the serum EGFRs as at least three times over a minimum of three months. If we want to really.
[00:21:08] Find out what's the rate of progression. And I think that would bring to the point that how can we delay the progression of the CKD? And it is going to be a combination of several factors, which includes lifestyle factors, where low salt. keeping fit, low body weight and not smoking and not drinking excessively are important.
[00:21:31] And I think it's also important that if the patients are on CKD register, they need to be told that they would be monitored. If they are not on the CKD registers, they might go unmonitored. Yes, there are going to be various medicines which need to be optimized. And that includes the ACE. SGLT2 inhibitors, uh, the finerenone, and we have the GLP 1 class, which is also the upcoming thing.
[00:21:58] Another important bit would be having a good diabetes control, which again is really quite helpful in delaying the progression of the chronic kidney disease. And something which is vitally important is a good blood pressure control. These patients also need to be on statins because there is cardiovascular risk, which is associated with having chronic kidney disease.
[00:22:24] As I think we locally are hoping for having some dedicated chronic kidney disease guidelines from the Midlands Kidney Network, which is waiting for final approval. I think Catherine, you can expand on this more.
[00:22:39] Catherine Byrne: Uh, yeah, because I'm the CKD. Subgroup lead for the renal network for the Midlands and we've developed a three step solution and this is being sent to the oversight board for final approval and effectively what we want is early identification for all the reasons we've outlined.
[00:22:59] So if you're identified early, you get on your CKD register, people are then ensuring that you're recalled for regular monitoring, for your blood pressure, for your urine ACR, looking for changes. very much. but also ensuring that you optimize their care with lifestyle advice, access to gyms or physical activity programs, alcohol, smoking cessation.
[00:23:24] So all of the lifestyle changes. And then on top of that, all of the new medicines that are now available to us, the armament we've now got is greater than it's ever been. For years, it's been limited to RAS blockade with ACE. an ARB medication, but now, as we've mentioned, we've got SGLT2 inhibitors, fineranone, and coming along the lines of the GLP 1.
[00:23:47] And then ultimately, once you've optimized care, you also want to identify those who are at greatest risk. So those who need prompt referral onto secondary care. So what we've alluded to, this is primarily those with a kidney failure risk score of greater than 5 percent in 5 years. But again, there are caveats to that because some people it may not be appropriate.
[00:24:10] But you need to remember that the KFRE gives you a risk score at one point in time. That equation does not know what's happened to someone's kidney function or their ACR prior to you making that calculation. So, for that reason, those with accelerated progression, as Rahul's explained, with a sustained decrease in GFR of 25 percent or more over 12 months, or a sustained decrease in GFR of 15 mls per minute within a 12 month period.
[00:24:42] Also, obviously, there are those people who've got nephrotic syndrome, et cetera. So it's all about three steps, early identification, optimization, and prompt referral to secondary care.
[00:24:53] Irina Varlan: I see. Thank you both for all this information.
Resources for Patients with CKD
[00:24:56] Irina Varlan: So far, we spoke a lot about the guidelines and resources for clinicians, but can patients access this level of information in a friendly format?
[00:25:06] We talked about urine and blood test values, parameters, medicines, and stages. It can be quite overwhelming. There are a lot of acronyms in medical language. Could you talk through the resources available for patients suffering with CKD?
[00:25:22] Catherine Byrne: Sure. Thanks, Irina. There are lots of tools that patients can access because obviously it can be very frightening getting a diagnosis of chronic kidney disease.
[00:25:30] or some people may not understand the implications. The Leicester renal team have done some amazing YouTube videos, which we'll create a link to with the podcast note that are specifically targeted at patients with chronic kidney disease. It's in plain English, easy to understand. And there actually are options for other languages and there's subtitles that can be used for those videos.
[00:25:54] There's a wide array of podcasts and videos that patients themselves do that are out there to access online. And in fact, some GP colleagues elsewhere have done podcasts. We ourselves have done some information about drugs, but that has been more geared towards primary care and secondary care colleagues.
[00:26:10] One really amazing asset is the kidney patient association. So this is for all patients with kidney disease, no matter what severity, whether it's CKD, on dialysis with a transplant, and it supports people in a number of ways, both with educational information, simple things about what do your kidneys do, where are they, how it may affect your general health, how you can look after your general health and your kidneys.
[00:26:38] But they're also really good as signposting you for financial resource, what benefits you may be entitled to, as well as psychological wellbeing. There's something called Kidney Beam, which is a national run online service looking at health and wellbeing for patients with kidney disease. It is specifically targeted.
[00:26:59] People with kidney disease, again, all ages, all severities, and that is currently free to join because the Renal Network paid for that. It was a 10 subscription, but it's now free as soon as you put your postcode in. There's obviously nice guidance that have a patient's versions of the guidance, so again, that should be an easy to understand language.
[00:27:21] There is obviously the accessibility to their records through the NHS app, where a patient can also, as well as seeing letters. And what medication they take can access their result. And for those in secondary care, there is something called patient knows best, which is also available through the NHS app for people in primary care, and as well as showing the numbers that sort of biochemistry results, the urine ACR result, it will explain to the patient what those numbers mean, obviously for people with cardiovascular disease and diabetes, they've got access to other national bodies in particular.
[00:27:56] patient affiliated bodies. And just recently there's been a campaign called Know Your Numbers, which is basically encouraging clinicians, be they doctors, pharmacists, specialised nurses, to rather than just say to someone your blood pressure's fine, actually give them the precise numbers so they can take charge and they're empowered to know what to look for.
[00:28:18] Thank you.
[00:28:18] Irina Varlan: You mentioned quite a few interesting resources for patients, and I must confess I was not aware of some of them. We will definitely link them in the podcast notes. When you mentioned the three step approach, you talked about referring to secondary care, and my next question is regarding that.
Referral to Secondary Care
[00:28:37] Irina Varlan: When do we know that we need to refer patients to secondary care?
[00:28:42] Catherine Byrne: Okay, in part, this is very much supported by some recommendations in NICE guidance. So NICE would suggest anybody with a kidney failure risk score of greater than five percent in five years should be considered for referral to secondary care.
[00:29:01] Again, that shouldn't be a hard value and some of this is really dependent upon clinical judgment. Because if you were 35, clearly that person would be coming into secondary care. But if you were 94 bed bound in a nursing home, it might be felt that actually it's inappropriate to try and get that person up to the kidney clinic.
[00:29:24] It's also suggested people with higher levels of proteinuria, so anyone with an ACR of 70 or more, or if we've checked a urine PCR protein creatinine ratio of 100 or more, Unless it's specifically known to be due to diabetes and already appropriately treated. Anyone with albuminuria, so an ACR of 30 or more with haematuria, because that could be a marker of glomerulonephritis, so inflammation within the glomerulus, obviously having excluded a UTI.
[00:29:58] As we've mentioned before, people who've got signs of rapid progression, so an EGFR decline of more than 15 mils per minute. or a greater than 25 percent decline of their EGFR within a 12 month period. Hypertension, particularly if it's difficult to control, so that is someone who's on at least four antihypertensive agents.
[00:30:23] People with or suspected of having genetic causes, so for example, autosomal dominant polycystic kidney disease or port syndrome. Anyone you suspect may have renal artery stenosis. anyone you think who might have nephrotic syndrome and actually people with anemia that you may feel would benefit from some erythropoietin agents.
[00:30:48] I think if you're unsure and they don't clearly fit into one of those NICE criteria that's not to say that they shouldn't necessarily be referred on to us. I'm more than happy to receive advice and guidance or referral letters because Some of this is down to clinical judgment and these nice targets.
[00:31:06] They are guidelines. It's not a strict you have, you can only be referred if you fulfill one of these criteria.
[00:31:13] Irina Varlan: Thank you Catherine for that. Now we know NICE covers in a lot of detail how to manage. chronic kidney disease in primary care, and we don't necessarily want to go in all the details, but I'd like us to touch on the latest understandings in terms of new medication options.
[00:31:28] You've mentioned them before, but should we try and look at each one of them and just briefly say what we know so far, how well we're doing?
[00:31:36] Catherine Byrne: Yeah, sure. So the oldest drugs that we've known that have been available to us are the RAS blockade. So that's the ACE inhibitors So we know from data that we're pretty good at prescribing these, but what we don't know is what dose people are on.
[00:31:53] So the first thing is optimizing ACER, so maximum tolerated doses, and that might be limited because of hyperkalemia, though there are agents that can help with that such as localma, or it might be because their blood pressure's too low and they can't tolerate a higher dose. If you then go on to the newer agents, the SGLT2 inhibitors, so these have been around for many years and again, we've, we've done a separate podcast on these, but if you look at our data across the ICBs for prescribing SGLT2 inhibitors, DAPA CKD got its NICE approval in March 2022 and Empagliflozin just in December last year and Canagliflozin is currently under review from NICE.
[00:32:41] If you look at prescribing for dapagliflozin and empagliflozin across the ICBs, it's been a reasonably slow uptake over time, but there's a long road ahead, a call for action for us to try and get as many patients who are eligible. for these drugs taking them. There's then been the finerenone data looking at people with diabetes and diabetic nephropathy.
[00:33:04] These have got quite tight restrictions because you've got to have a potassium of less than five, five or less when you actually prescribe the agent. So a lot of our patients who are already on ACE inhibitors may have potassium readings over that. Actually, there's some good data to show that SGLT two inhibitors do actually reduce your potassium readings.
[00:33:28] So if you're on an SGLT two inhibitor as well, there may be room to maneuver to add in phenome. And then lastly, specific for kidneys, there's been the GLP one data. So there's been a recent trial called Smart C, which was a randomized double blind placebo trial. And interestingly, it looked at. diabetes, cardiovascular and kidney outcomes.
[00:33:53] And basically it appeared to show a benefit in all of these outcomes. And the findings suggested it was independent of what other therapies that the patient was on. So it's additional value. It basically looked at cardiovascular events, heart failure, hospitalization, cardiovascular death, and chronic kidney disease progression.
[00:34:18] And that has literally just been published this year. So I think there's lots of promising data for kidney specific medication, but we also have to remember, as we've alluded to before, that obviously our patients do have lots of other cardiovascular diseases, so it's really important, as Rahul's alluded to, about ensuring these patients are on statins and that they've got good diabetes and good blood pressure control.
[00:34:48] Irina Varlan: Thank you for that, Catherine. And to end, because I'm sure we can spend a lot more talking about chronic kidney disease.
Key Takeaways for Primary Care Clinicians
[00:34:55] Irina Varlan: Can we focus on a couple of things that primary care clinicians should remember from today's conversation to help improve the outcome of their own patients with CKD?
[00:35:04] Rahul Mohan: Yes. Now, so I think what's really quite important is that there should be an early identification and then the intervention can happen.
[00:35:12] And I think another important thing is that there should be an accurate clinical trial. coding of the diagnosis in our electronic health records. So maintaining an accurate CKD register and also making sure that it is a true reflection of the prevalence of the condition. Recognizing these patients is important because a lot may also have other long term conditions like diabetes, hypertension, and cardiovascular disease.
[00:35:38] I think one thing we should remember is that chronic kidney disease does not. occur in isolation. It's often a part of the various spectrum of diseases that we are having. And I think for the primary care, the medicine optimization is something which is key, and that would significantly reduce the use the risk of a CKD progression and then ultimately saves life and I think there is a very strong argument that this is going to be economically very effective over time.
[00:36:12] Another important aspect for the primary care is that there should be a prompt referral for these patients who are at a risk of CKD. progression to the end stage disease, those patients who require renal replacement therapy. So it is important that these patients also are prepared for these therapies, which might be down the line.
[00:36:35] Catherine Byrne: And I think I'd agree with all of that. I think it's. important that it's a simple three step. So identify, optimize, and prompt referral. And as I've alluded to, there is some more detail about SGLT2 inhibitors and finerenone on two other podcasts we've done. We're always as a department happy to help with any advice and guidance or concerns that people have got.
[00:37:02] And on a wider point, as part of the CKD network, we're always very keen for people from. primary care to get involved because I think it's all about teamwork and we in secondary care recognize that most of these people are actually sat in the community being looked after by our primary care colleagues and so we're here to try and support you guys out in the community to try and ensure that our patients are given the best care they possibly can be.
Conclusion and Final Thoughts
[00:37:33] Irina Varlan: Thank you both for giving me your time. I found our conversation today valuable. I heard a lot of interesting facts about chronic kidney disease, and I'm really grateful you were able to come today on the episode and share your experience. Thank you.
[00:37:46] Catherine Byrne: It's been a pleasure.
[00:37:47] Rahul Mohan: Thank you. Thank you, Kat, irina.
[00:37:50]
