Chronic kidney disease: the canary in the coal mine
Chronic kidney disease is a common condition that is costly to manage. Most of the costs are linked with advanced kidney disease and the associated cardiovascular disease. Fortunately, there are now several treatments that can not only slow the progression of chronic kidney disease but also reduce the burden of cardiovascular morbidity and mortality. To do this effectively, patients need to be diagnosed as early as possible, as only then can optimal preventative measures, both lifestyle and pharmaceutical, be deployed. With the scale and complexity of chronic kidney disease, timely access to specialist care is increasingly required. Referral criteria have changed, with more focus on the 5-year risk of developing end-stage renal disease by using the four variable kidney failure risk equation. One of the major limitations to the effective treatment of people living with chronic kidney disease is hyperkalaemia. The appropriate frequency of testing, assessment and management of hyperkalaemia helps not only reduce the risk of dying from the condition, but also from chronic kidney disease and heart failure, as too often sub-optimal treatment with renin-angiotensin-aldosterone system inhibitors impairs optimal care.
Chronic kidney disease is commonly seen in primary care.
Life in primary care in 2023 is tough: there are workforce shortages (Deakin, 2022), an increased number of consultations (British Medical Association, 2022) and, perhaps the most challenging, a massive backlog of routine care (Oliver, 2022).
One thing the pandemic has reminded us of is that healthcare needs are far from uniform. Some people or communities are at greater risk of harm than others (Williamson et al, 2020). With limited resources, in a publicly-funded healthcare service, we need to focus our efforts on patients who are at the highest risk of harm. Cost-effective tests need to be used that can identify people at risk of poor and expensive outcomes.
The ‘canary in the coal mine’ is a term that comes from the old mining practice of using caged canary birds, who are extremely sensitive to carbon monoxide, to warn the miners of the impending danger of rising levels of that gas. Chronic kidney disease (CKD) can be seen as a similar early warning sign that all is not well in the cardiovascular system of the person being treated. CKD is a common condition, affecting 5% of people aged 75 and over, similar in prevalence to other conditions, such as diabetes (NHS Digital, 2016). It is defined by abnormalities of kidney structure or function, persistent for more than 3 months, with implications to health (KDIGO, 2013). The financial cost, based on data already acquired over 10 years ago, is £1.45 billion (Kerr et al, 2012). Most of these costs are for renal replacement therapy, such as dialysis. The rate of dialysis continues to increase year on year (UK Renal Registry, 2021) and so this condition is financially expensive. The quality of life for a person living with CKD is massively reduced (Nguyen et al, 2018) and mortality is also increased. The most common cause of CKD in the UK is diabetes. The combination of developing CKD with diabetes is associated with up to a 16 year decrease in life expectancy (Wen et al, 2017). There is a close association between advancing CKD and increased hospital admission, particularly from cardiovascular causes, such as heart failure (Kalantar-Zadeh et al, 2021). Cardiovascular disease remains the leading cause of mortality in people with CKD (National Institute of Health and Care Excellence (NICE), 2021a), with approximately 10% of people with CKD surviving to renal replacement therapy (United States Renal Data System (USRDS), 2020).
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