Practice Nurse bite-sized learning: Understanding chronic kidney disease

INTRODUCTION

Chronic kidney disease (CKD) is a long-term condition where the kidneys do not work effectively due to abnormalities of the structure or function that are present for a minimum of three months.¹ The kidneys have five main functions:

• Balance levels of salt and water
• Excrete waste from the blood
• Control blood pressure
• Make strong bones
• Boost production of red blood cells

WHAT'S THE PROBLEM

Around 7.2 million people in England have diagnosed CKD, and there are thought to be around a million people who have the condition but who are undiagnosed.² CKD can substantially reduce quality of life and leads to premature death for thousands of people each year, even at early stages. It is also a major driver of health inequalities, with a disproportionate burden on ethnic minority groups, such as those from South Asian backgrounds with diabetes, who are ten times more likely to develop end stage kidney failure than Caucasian people with diabetes.

DETECTION

CKD does not usually cause symptoms until it reaches an advanced stage so proactive case finding is essential and should be targeted at the following population groups:

Adults with:

• Diabetes
• Hypertension
• Heart disease and/or heart failure.
• Family history of CKD or kidney failure
• Personal history of acute kidney injury (AKI)
• Structural renal tract disease, renal calculi or prostatic hypertrophy
• Multisystem diseases such as Systemic Lupus Erythematosus (SLE) or HIV
• Gout

DIAGNOSIS

Testing for CKD should include measurement of estimated Glomerular Filtration Rate (eGFR) and urinary albumin creatinine ratio (uACR). Those with abnormal results should be retested in 3 months’ time before the diagnosis can be confirmed and classification can take place (Table 1).⁴ A lack of uACR measurement i.e. measurement of eGFR only, may lead to underdiagnosis, underestimation of severity and underestimation of risk in the individual.

MANAGEMENT

Management of CKD should include:^1,4

1. Evaluation of risk

• QRISK3 (if available or QRISK2) for CVD risk, be aware of underestimation of risk as uACR not included
• Kidney Failure Risk Equation (Figure 1)

2. Medicines optimisation

• Blood pressure control (Table 2)
• Maximum tolerated inhibition of Renin Angiotensin Aldosterone (RAAS) system with ACE inhibitor or Angiotensin Receptor Blocker
• Lipid lowering therapy
• Sodium-glucose transport protein 2 inhibitor (SGLT2i): dapagliflozin or empagliflozin
• Mineralocorticoid receptor antagonist (MRA): fineronone

3. Optimisation of long-term conditions

4. Patient education

• Lifestyle including smoking, diet, physical activity, salt and alcohol intake
• Vaccinations including Flu, pneumonia and COVID
• ‘Over the counter’ medications including NSAIDs such as ibuprofen that are nephrotoxic
• Sick day rules – prevention of AKI with dehydrating illnesses e.g. diarrhoea

5. Early identification of frailty

REVIEW

Patients with CKD should be added to the register for a minimum of annual recall for review.³ eGR and uACR should be checked at least annually and up to 4 times per year for those at highest risk.¹ As well as routine monitoring of blood pressure and pulse, auscultation of the heart sounds should also be carried out by an appropriately skilled clinician. Heart valve disease is common in people with CKD and regular monitoring is essential.¹

REFERENCES

1. KDIGO 2024 Clinical Practice Guidelines for the Evaluation and Management of Chronic Kidney Disease. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf

2. Kidney Care UK. Facts about kidneys; 2024. https://kidneycareuk.org/kidney-disease-information/about-kidney-health/facts-about-kidneys/

3. Kerr M. Chronic Kidney Disease in England: the human and financial cost; 2012

4. NICE NG203. Chronic kidney disease: assessment and management; 2021. https://www.nice.org.uk/guidance/ng203