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Optimise Identification and Management of Chronic Kidney Disease

Dr Raj Thakkar and Dr Jim Moore Discuss the Importance of Early Diagnosis of Chronic Kidney Disease, Providing Practical Advice for Primary Care Practitioners

Read This Article to Learn More About:
  • the association between chronic kidney disease (CKD) and cardiovascular disease
  • current guidelines and treatment options for CKD
  • optimising CKD management in primary care through quality improvement.
Key points and implementation actions for clinical pharmacists in general practice can be found at the end of this article.

Reflect on your learning and download our Reflection Record.

Chronic kidney disease (CKD) is a long-term condition characterised by abnormal kidney structure or function, which is defined by the presence of kidney damage, decreased kidney function, or both, for at least 3 months.1,2 CKD prognosis is classified based on cause, glomerular filtration rate (GFR) category, and degree of albuminuria (indicated by urinary albumin:creatinine ratio [ACR])—see Figure 1.1–3 

Figure 1: Prognosis of CKD by GFR and Albuminuria Categories1

photo of
CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health. CKD is classified based on Cause, GFR category (G1–G5), and Albuminuria category (A1–A3), abbreviated as CGA.

Green: low risk (if no other markers of kidney disease, no CKD)
Yellow: moderately increased risk
Orange: high risk
Red: very high risk.

CKD=chronic kidney disease; GFR=glomerular filtration rate; CGA=Cause, GFR, Albuminuria

© Rossing P, Caramori L, Chan J et al. KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int 2022; 102 (5S): S1–S127.

The Burden of CKD

CKD places a huge burden on patients, their families, and the economy. It is estimated that around 15% of people aged 35 years or older in England have CKD, and the condition results in an annual cost of approximately £1.4 billion to the NHS.4,5

In addition, CKD confers significant cardiovascular risk, and is one of the six high-risk conditions for the development of cardiovascular disease (CVD) recognised by CVDPREVENT, the national primary care audit for CVD prevention.6 CKD alone appears to confer a greater risk of cardiovascular events than diabetes,7 and this risk is amplified in patients with diabetic kidney disease (DKD).8 The cardiovascular risk of CKD is further elevated by increased ACR or decreased estimated GFR (eGFR), as both are associated with a greater risk of adverse CKD outcomes and are independently associated with early mortality, even at early stages.1,9–12 In combination, increased ACR and decreased eGFR multiply the risk of adverse outcomes, as can be seen from the standard categorisation of CKD risk outlined in Figure 1.9,10,12

Furthermore, CKD can have significant detrimental consequences, and patients may require dialysis or kidney transplantation in end-stage renal disease (ESRD).13,14 According to the 2017 National CKD Audit (NCKDA), for every 100 patients with CKD and moderate-to-severe impairment of kidney function, each year there are:13

  • seven acute kidney injury events
  • six cardiovascular events
  • seven deaths
  • 38 unplanned hospital admissions
  • two admissions to an intensive care unit.
The detrimental consequences of CKD and the burden it imposes highlight the importance of early identification, diagnosis, and management for optimising patient outcomes. 

Early Diagnosis

Because CKD is often asymptomatic until it is at an advanced stage, many people with the condition remain undiagnosed—in fact, a 2020 population-based cohort study estimated that, without screening, as many as 44% of cases are going undiagnosed in the UK.4,11 These missed cases reflect the suboptimal investigation of potential CKD in primary care.

When to Suspect CKD

Some patient groups are at increased risk of developing CKD, including those with established CVD, hypertension, diabetes, or gout, and those taking nephrotoxic drugs.15 The disease should be suspected in patients with risk factors for CKD, or possible clinical features or an incidental finding of:16

  • ‘raised serum creatinine levels and/or a serum [eGFR] of less than 60 ml/min/1.73 m2
  • proteinuria (a [urinary ACR {uACR}] of more than 3 mg/mmol)
  • persistent haematuria (two out of three urine dipstick tests show[ing] 1+ or more of blood), after exclusion of a urinary tract infection …
  • urine sediment abnormalities, such as red blood cells (may indicate glomerular disease); white blood cells (may indicate pyelonephritis or interstitial nephritis); or granular casts and renal tubular epithelial cells (seen in many parenchymal diseases).’
NICE guidance emphasises that both eGFR and uACR must be checked whenever suspected CKD is investigated,9,17 in part to ensure the early identification of CKD. However, the results of the 2017 NCKDA demonstrate that a large proportion of patients with risk factors for CKD do not have routine blood or urine tests to test for this comorbidity.13,18 Specifically, as of 2017:13
  • 86% of people with diabetes were tested for CKD annually, but only 54% underwent the requisite urine tests
  • fewer than 30% of people with CKD risk factors other than diabetes underwent uACR tests for CKD
  • almost all general practices in England had given eGFR tests to over 90% of their patients with hypertension in the preceding 5 years, but they had only given uACR tests to 10–50% of these patients.
Gaps in uACR testing contribute to both underdiagnosis of CKD and underestimation of its risk and severity.11,13,19 As such, the report on the NCKDA’s findings identified increased uACR testing as an essential improvement in all healthcare sectors.13,18

Best Practice in the Management of CKD

Both NICE and Kidney Disease: Improving Global Outcomes have developed clinical guidelines for the identification and management of kidney diseases.9,20 In general, the management of CKD should include treatment of underlying conditions, prevention of disease progression, symptomatic relief, and optimal management of comorbidities, such as hypertension and diabetes, and complications, such as anaemia.9,21

Pharmacological Treatment of CKD

The mainstay of CKD treatment is renin–angiotensin–aldosterone system inhibitor (RAASi) therapy, with angiotensin-converting enzyme inhibitors (ACEis) or angiotensin-receptor blockers (ARBs).9 Therapeutic options are primarily guided by the person’s ACR and therapeutic response, and any comorbidities.9 Titration of these therapies to the maximum licensed dose that each patient can tolerate is essential.9 

NICE’s recommendations on therapy for proteinuria in CKD are outlined in Figure 2.9,22

Figure 2: NG203 Visual Summary: CKD Assessment and Management—Managing Proteinuria22

NG=NICE Guideline; CKD=chronic kidney disease; ACR=albumin:creatinine ratio; ACE=angiotensin-converting enzyme; ARB=angiotensin-receptor blocker; SGLT2=sodium–glucose co-transporter-2; eGFR=estimated glomerular filtration rate

© NICE 2021. Chronic kidney disease (G1–5, A1–3): managing proteinuria. Visual summary. NICE Guideline 203. NICE, 2021. Available at:

All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. See for further details.

Pharmacotherapy for Diabetic Kidney Disease

Patients with DKD are at a greater risk of morbidity, including ESRD and premature mortality, than patients with CKD alone.23 For these patients, consideration can be given to the addition of a sodium–glucose co-transporter-2 inhibitor (SGLT2i)24—at the time of publication, dapagliflozin was the only SGLT2i licensed for this indication.25,26

Finerenone is a relatively new, highly selective, nonsteroidal mineralocorticoid receptor antagonist27,28 that has been shown to reduce the risk of CKD progression and cardiovascular events in patients with concomitant CKD and type 2 diabetes compared with placebo.29 Indeed, in March 2023, NICE released new technology appraisal guidance for the use of finerenone in adults with stage-3 and -4 CKD (with albuminuria), type 2 diabetes, and an eGFR of 25 ml/min/1.73 m2 or greater, as an add-on to optimised standard care with RAASi therapy and an SGLT2i.23

The Role of the Primary Care Team

Given the detrimental consequences of CKD, the advent of therapies like finerenone and SGLT2is, which can slow disease progression, places even greater importance on identifying and managing CKD early in the course of the disease. Primary care teams play an essential role in these efforts by proactively identifying people with, or at risk of, CKD and undertaking eGFR and uACR testing accordingly.13

Correct Coding

Another improvement that the NCDKA report identified as essential in CKD management is accurate coding in clinical systems; in the audit, only 70% of biochemically confirmed cases of CKD were correctly coded, and high regional variability was evident in the accuracy of coding practices.13 Once a diagnosis is confirmed, clinicians must code patients accurately on clinical systems, thereby helping to optimise management of the patient’s CKD and comorbidities and ensure regular review of their kidney function. Improving CKD coding may also contribute to safer prescribing, reduce emergency hospital admissions, and allow the provision of personalised information and education on CKD to patients.13,30

The PCCS CKD Quality Improvement Programme

The Primary Care Cardiovascular Society (PCCS) is a multidisciplinary society that promotes best practice in cardiovascular healthcare in primary care through education, training, and service development.31 Given the increased risk of cardiovascular events with CKD, and the need for training on CKD and quality improvement (QI) identified in the NCKDA report, the PCCS has developed an educational resource for primary care—the PCCS CKD Quality Improvement Programme—that practitioners can use to optimise the identification and management of CKD.13,32

Developed in conjunction with primary and secondary care clinicians, the resource is designed to support primary care teams to enhance the quality of care for patients with, or at risk of, CKD. The programme presents an opportunity for primary care teams to transform their CKD care pathways and, by promoting earlier CKD diagnosis and evidence-based treatment optimisation, it represents a valuable resource for QI activities related to CKD. On a wider scale, the resource also supports primary care in delivering the CVD prevention ambitions of the NHS long term plan.32,33

The programme comprises four modules encompassing all aspects of CKD identification and management.32 It is available to members of the PCCS as four educational videos on the Quality Improvement section of the PCCS website.32 Box 1 provides further details on each module.

Box 1: Outline of the PCCS CKD QI Programme
  1. CKD prevention and diagnosis—covering the epidemiology of CKD, its association with CVD, the importance of early diagnosis and monitoring, and QI ideas for CKD in primary care
  2. Coding and searches—focusing on the importance of coding and searches for CKD management and identification. This module also provides clinicians with information and access to CKD searches that have been, or are currently being developed by, two organisations—North East and North Cumbria Academic Health Science Network and UCLPartners—for use in their practice
  3. Treatment and management—encompassing the primary care management of CKD, including CVD risk, and discussing evidence-based therapeutic options. This module also covers the benefits of virtual consultations in allowing access to specialist advice for care optimisation in CKD
  4. Preparing for ESRD/dialysis—discussing ESRD, dialysis, and the importance of shared decision making with patients and their families.
PCCS=Primary Care Cardiovascular Society; CKD=chronic kidney disease; QI=quality improvement; CVD=cardiovascular disease; ESRD=end-stage renal disease


CKD is a progressive condition and a leading cause of mortality worldwide.34 Symptoms may not present until an advanced stage, and patients may eventually require dialysis or kidney transplantation. Healthcare teams must therefore act now to support early identification and prompt treatment of this disease. The PCCS aims to assist primary care in addressing this burden through its CKD QI programme.

Key Points
  • CKD is a long-term condition that is classified according to cause, GFR category, and degree of albuminuria
  • Both increased ACR and decreased eGFR are associated with an increased risk of adverse outcomes for patients with CKD
  • Primary care teams can support the early identification of patients with, or at risk of, CKD to help optimise outcomes
  • CKD should be suspected in patients with clinical features, risk factors, or an incidental finding that is suggestive of abnormal kidney function
  • There are currently gaps in uACR testing for patients with risk factors for CKD that must be addressed in primary care to improve the diagnosis of CKD
  • CKD is recognised as a major risk factor for the development of CVD, and this risk is enhanced in patients with concomitant type 2 diabetes
  • Management of CKD, both with and without type 2 diabetes, primarily comprises optimised RAASi therapy, with dapagliflozin and finerenone as add-on treatments where indicated, in line with national and international clinical guidance
  • In March 2023, finerenone was endorsed by NICE for use in patients with CKD (stages 3 and 4), type 2 diabetes, and an eGFR ≥25 ml/min/1.73 m2, in conjunction with optimised standard care
  • The PCCS aims to improve cardiovascular health through education, and has developed a CKD QI programme to support primary care HCPs to enhance CKD care pathways.
CKD=chronic kidney disease; GFR=glomerular filtration rate; ACR=albumin:creatinine ratio; eGFR=estimated glomerular filtration rate; uACR=urinary albumin:creatinine ratio; CVD=cardiovascular disease; RAASi=renin–angiotensin–aldosterone system inhibitor; PCCS=Primary Care Cardiovascular Society; QI=quality improvement; HCP=healthcare professional
Implementation Actions for Clinical Pharmacists in General Practice

Written by Shivangee Maurya, Clinical Services Pharmacist, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general practice with implementing guidance at a practice level.

As highlighted in the NCKDA report, there is a need for training on CKD and QI.[A] The PCCS CKD Quality Improvement Programme is a valuable resource for clinical pharmacists in general practice to improve the identification and management of CKD in practice.

The NCKDA report identified that only 54% of patients with diabetes had received the relevant annual urine tests.[A] This is an area in which practice-based clinical pharmacists are well placed to lead a diabetes CKD QI project. Below are some points to consider before embarking on a QI project:

  • determine practice performance—where does your practice or PCN stand regarding indicators measured in the NCKDA? Once you have identified any areas for improvement, complete your root-cause analysis utilising the fishbone diagram as outlined in the PCCS toolkit
  • identify patients who should be included in the QI project—given that CKD has an estimated prevalence of 15% in people aged ≥35 years in England,[B] it is important to have a strategy to identify, code, and prioritise patients appropriately. Patients with diabetes are a key cohort to review, ensuring that they have had their urinary ACR checked. This will support the identification of patients with CKD
  • utilise the leanest role—assess your team and decide who is best placed to do which task. For example, a pharmacy technician could run searches to identify all patients with diabetes who have not had their urinary ACR tested or who require a review. When completing diabetic reviews, utilise your healthcare assistant to complete some of the checks (such as foot checks) and collect urine samples for urinary ACR testing
  • upskill and educate—ensure that the clinical team completes training to upskill on CKD guidelines and any newer treatment options such as finerenone, a highly selective nonsteroidal mineralocorticoid receptor antagonist. Share your knowledge as a clinical pharmacist working in general practice; some clinical changes that are second nature to you may not be to other clinical team members. Relevant topics include:
    • the importance of coding, and the risk posed to patients if this is done incorrectly
    • nephrotoxic drugs
    • the difference between CKD and acute kidney disease, and how this influences the treatment plan
    • the importance of checking urinary ACR.

Soar Beyond Ltd is dedicated to supporting QI and optimisation of the multidisciplinary team.Our i2i Network provides clinical pharmacists in general practice with digital tools and change-management support for QI projects,with a suite of training and 4D™ implementation resources. To ensure you don’t miss out, sign up for free now or find out more about our i2i Network by visiting

[A] Nitsch D, Caplin B, Hull S, Wheeler D. National CKD Audit // national report (part 1). London: LSH&E, 2017. Available at:

[B] Hirst J, Hill N, O’Callaghan C et al. Prevalence of chronic kidney disease in the community using data from OxRen: a UK population-based cohort study. Br J Gen Pract 2020; 70 (693): e285–e293.

NCKDA=National Chronic Kidney Disease Audit; CKD=chronic kidney disease; QI=quality improvement; PCCS=Primary Care Cardiovascular Society; PCN=primary care network; ACR=albumin:creatinine ratio