CKD care has improved but GPs should conduct more urine tests, report says

GPs have helped cut the need for dialysis among patients with chronic kidney disease (CKD) through earlier diagnosis over the last decade, but greater use of annual urine testing and accurate read coding could boost progress further, according to a clinical audit.

Blood tests are widely used, but urine tests are being missed
Blood tests are widely used, but urine tests are being missed

Earlier diagnosis of CKD has helped cut the number of patients starting dialysis from one in three to less than one in five over the past decade thanks to efforts from primary care, a report has found.

But results from the CKD audit, the first of its kind, suggest there is wide variation in diagnostic testing of CKD across practices, with urine testing in particular being underused.

Annual monitoring is required to manage most cases and identify patients at risk of developing kidney disease. NICE recommends that this should include both blood tests for eGFR and urinary testing for albumin to creatinine ratio.

The audit, compiled with data from 911 practices in England and Wales, found that some 86% of GPs conducted annual blood tests with patients, while 54% did urine tests.

Experts suggested this could be because patients do not understand what the test is for, find the process more awkward or that it is an extra step in the annual check-up that is easy to miss without a small amount of pre-planning.

CKD monitoring

The audit also recommends more effective use of read coding for CKD to ensure they are monitored and given appropriate advice, after finding that a third (30%) of patients with biochemical evidence of the condition were not recorded.

The proportion of un-coded patients ranged from 0% to 80% across different practices .

CKD affects around one in 20 adults, particularly older adults or patients with diabetes and high BP.

Many patients do not experience symptoms until the very advanced stages, with some going on to develop cardiovascular disease or acute kidney injury.

Dr Richard Fluck, former national clinical director (renal) at NHS England, said: ‘Chronic kidney disease is important and whilst we have made significant progress in diagnosis and treatment over the last decade there is still unmet need in care.

‘Historically, CKD was often not diagnosed in a timely way, reducing options to slow disease progression and prepare people for the possibility of kidney failure. This occurred in about one in three people starting dialysis over a decade ago and is now less than one in five.

GP diagnosis

‘That improvement is down principally to the skills of primary care in understanding the need to detect and manage CKD.'

Fiona Loud, policy director at the British Kidney Patient Association, said: ‘By calling attention to current practice patterns and offering practical evidence and guideline-based recommendations for improvement, the report is encouraging as it shows it’s possible to improve in a short space of time.

‘The report can help GPs to make best use of resources by focusing on, monitoring and managing those at risk, preventing complications and deterioration where possible.’

The report was commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit (NCA) programme.

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