Conflict over CKD treatment

Chronic kidney disease (CKD) patients with proteinuria should be treated with ACE inhibitors or angiotensin receptor blockers (ARBs) irrespective of BP, according to draft guidelines.

The Scottish Intercollegiate Guidelines Network (SIGN) draft recommendations on the management of CKD conflict with the GMS quality framework, which states that ACE inhibitors and ARBs should only be given to patients with stage-three to five CKD if they have hypertension.

The SIGN recommendation could reignite GP's concerns about over-treatment of elderly patients labelled CKD as a result of errors in estimated glomerular filtration rate (eGFR).

Previously, County Antrim GP Dr James Kenny said eGFR was 'meaningless' in older patients and could lead to stage-three CKD being incorrectly diagnosed and treated (GP, 19 May 2006). He called for the use of exception reporting in these circumstances.

SIGN says that all CKD patients with proteinuria 1g per day or microalbuminuria should receive ACE inhibitors or ARBs first line to achieve a target maximum systolic BP of 130mmHg.

Morag Whittle, a renal pharmacist at Glasgow Royal Infirmary, who was involved in drawing up the guidelines, said: 'Irrespective of BP, if you use ACE inhibitors or ARBs you can slow down the progress of renal disease in patients with proteinuria or hypertension.'

Dr Charlie Tomson, a consultant nephrologist at Southmead Hospital in Bristol, said the SIGN recommendations were consistent with the 2005 UK CKD guidelines from the Renal Association. The SIGN guideline is open for consultation until 22 July.

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