I think the most important thing is that if your kidneys are working at a level which is not 100%, it is lower than 60%, then that you are aware of it, but you also understand it not to become anxious and not to become anxious about the need for dialysis in the future, but to be aware that there are perhaps things that you can do, like the healthy diet and the low salt, about keeping an eye on your blood pressure, making sure you do remember to take your tablets to lower your blood pressure, and because these things will help protect the kidneys. Please don’t smoke, because smoking damages that filter in the kidneys. It also has an effect on your blood pressure and your cardiovascular risk. So these things that you know about, you perhaps give more emphasis to if you know that your kidneys aren’t working so well.

Is there any dietary advice that would benefit patients with early stage CKD?

To, people think automatically because the kidneys get rid of end products, the proteins, that the things to avoid are proteins. My view for most of my patients is actually the big issue is to try and get them to lose weight, because if you can lose weight and get more active that will help lower your blood pressure, and that will help to protect your kidneys. The other big important factor is salt. So salt is in our diets. If you eat anything that has been made by somebody else it will have had salt put in it as a preservative, so bread, cereals, soups, anything that comes out of a jar or a tin will be full of salt. The highest salt product is actually Pot Noodle which has got the same salt content as sea water, so it can give you your salt intake and more for the day in a pot. So there is salt in every manufactured food, and the more salt we have the more that raises your blood pressure, and of course that is, will give you an adverse effect on your kidneys and your kidney function. It will cause you to, you could get puffy ankles and of course then what happens is people take water tablets and that has an, can have an effect on the kidneys. Best thing: avoid the salt in the first case. If you can do that, that will lower your blood pressure and that will help to keep you healthier. So I really focus on, on having a good, an optimum weight and to lower the salt in your diet. And that would be my focus, and just, just healthy eating. So fruit and veg, get out and about, be more active, because that is the best way to keep your kidneys healthy.

A lot of patients I have spoken to assume that there must be dietary advice out there that would help them, and they seem quite frustrated just by being told to eat healthily. They think information is being withheld for some unknown reason and that there must be something they can do beyond that.

Right. The big emphasis on kidney disease in the past has always been on those with more severe stages of kidney disease, so those who are coming to a stage when their kidneys need extra help and they might need dialysis. So all of the emphasis has been at that level and there have been some pretty horrible diets in the past for those people. They have different problems and they have much more severe problems about getting rid of these chemicals from the blood.

That isn’t the issue for our patients who have perhaps 50% kidney function. For them it’s not about the, helping their kidneys to work better by having less protein. For them it’s actually about helping their body to be more healthy and their cardio-vascular system be more healthy with the general advice we give for people who have got heart disease and high blood pressure, because at that level that’s the important thing for them. It’s their blood pressure and their cardiovascular system rather than thinking about the same dietary advice for people who have got much more severe stages of kidney disease.

I would just like to tell you a little bit about the NICE Guidelines. Now you will be aware that NICE is a government organisation which reviews the evidence for the treatment of certain conditions. There is, has been a chronic kidney disease Guideline but we have just been involved in the past two years in updating it, and in July of 2014 the updated guidance will be published. There will also be advice to patients and there will be other activities for patient support around this. So it will give you some idea of what the evidence is for your treatment. It will also give you some idea of what you might expect or what you should expect in practices or at the hospital looking after your chronic kidney disease. So it’s very useful for you to look at and also to feed back on it.

I’d just also like to say a little bit about my role, because I am, part of my role as, other than being a general practitioner, is to be involved in work at the College of General Practitioners, because it was recognised that chronic kidney disease isn’t well understood in Primary Care, in general practice, and so the College has appointed myself as a Clinical Champion and I am also going to be having a Support Fellow, and the idea is to try and raise awareness for patients and for doctors about chronic kidney disease in Primary Care. We will also be developing educational materials, working with the patient groups, such as the British Kidney Patients Association and the NKF, about producing the right information for people in practice and, again, it is about making the patient the centre of their care and giving them the information that they need to help look after themselves better, and having that knowledge I think, I know knowledge is power but I think it is, it is power for people with chronic kidney disease and we need to try and get it right for you.

Your practice might be invited to be part of a National Audit, so again raising the quality of care. The HQIP, which is another national organisation, has funded an audit project throughout the UK. – Sorry – has funded an audit project which will take place in England and Wales and which your general practice may be involved in, and the idea is to help identify patients in the practices who have chronic kidney disease and to help look after them better. And the GPs will be given information about how that may best be done. And you may have a letter or see a poster up in the practice about this project, and you will be invited to feedback and ask about it. But all of these projects are working together to try and improve the care for yourselves and other people like you who have got chronic kidney disease.

Are there any specific circumstances in which acute kidney injury might arise?

In my patients, the patients I get concerned about who have a moderate decline in their kidney function but they are taking lots of tablets or medicines, and particularly groups of tablets or medicines that can have, can make the kidneys slightly more vulnerable are those people taking drugs for heart failure and for high blood pressure. And these are drugs which fall in the category of either, we call them ACE inhibitors, and they often end in pril’, So you might have heard of drugs like ramipril’, perindopril’ and the other cousins of those drugs are something we call angiotensin receptor blockers’, and they tend to end in sartan’, so drugs like candesartan’, losartan. Now these, both families of drugs are actually life-saving drugs when they are used in the right circumstances they can help protect the kidneys. But the issue is if you have an illness such as diarrhoea and vomiting and that means that you are dehydrated and you drop your blood pressure. If you are taking these drugs which otherwise are very clever at lowering blood pressure, you can’t actually raise your blood pressure to help protect your kidneys. The kidneys really like to be, operate, at the right pressure. They like to have not too much, which can damage them, and not too little, which means they can’t filter. And if they can’t filter then you get a build-up of waste products in the blood stream and we pick that up on blood tests as acute kidney injury. So all patients who are taking combinations of either those A’ drugs, which are the ACE inhibitors, or the angiotensin receptor blockers, particularly when you are also taking water tablets, which we call diuretics, those are things like furosemide or bumetanide. There are other different water tablets such as spironolactone or eplerenone. Again these are tablets which are used to clear fluid and they will tend to lower blood pressure, which is great when theres too much fluid on board, but if you’ve got sickness or diarrhoea and you haven’t got enough fluid in the system and the body wants to hold on to it, they can have an adverse effect on kidney function. So remember that tablets work. They have, they’re important in the right circumstances but there are some circumstances where they may not be beneficial and that you should be aware of this. And often patients will have a card and be recommended to stop them or at least phone up, phone up either in-hours your own doctor, or your heart failure nurse if you have one or, or phone up the out-of-hours number and get some advice and ask about these tablets should you have sickness and diarrhoea.

So if somebody is unfortunate enough to have an episode of acute kidney injury is it something they can recover from?

Well we always used to think that people recovered completely. We now know that some people don’t, and that’s an issue. So you can start off with your kidney function being 50%. You can have an episode when your kidneys aren’t working very well with acute kidney injury it could drop perhaps down to 30%. It may recover partially. Perhaps to 40%. But often it doesn’t completely get back up to where you were. Now again, that may not have a long term effect it really start, depends on where you start. but these episodes could perhaps have been prevented or reduced by having the right advice and the right treatment.

Theres a big emphasis now in hospital, because we know that acute kidney injury isn’t uncommon, it’s not uncommon on the surgical wards if someone has a problem with bleeding, a lot of bleeding. It’s certainly not uncommon on the elderly wards perhaps after a stroke where people aren’t able to drink properly. So there are circumstances that it, that we recognise that it can occur, and there are big campaigns now and nationally about raising awareness of acute kidney injury and helping to protect peoples kidneys.

We have a special blood test that we use to assess kidney function, and that measures a waste product in the bloodstream, and it uses a formula to calculate how efficient your kidneys are working. And if the efficiency of the kidneys drops below 60%, in other words if that number – which we call glomerular filtration rate – if that drops below 60% and that has been present for over 3 months, then we think that a patient may have got chronic kidney disease.

So people wonder why we ask to test the urine when you have got chronic kidney disease, and that’s because testing the urine helps us to look at kidney function in a different way. So I’ve explained at the start that often we pick up chronic kidney disease by doing a blood test where we look for the waste product called creatinine, and you look at the level changing and rising as the kidneys work less efficiently. But we can also look at the efficiency of the kidneys working as a filter. Now the kidneys are remarkably clever. They filter our blood. They keep inside the blood stream all the things we want to keep in, and they allow out the waste products and metabolised drugs, and other things that we actually want to get rid of. And the idea is there is a membrane between the two layers which keeps the things we want to keep in and allows the other things to get out.

Now there are processes that can damage that membrane so it allows things to get out into the urine that wouldn’t normally be there. And the thing we look for particularly is a small protein called albumin, and that detects very small amounts of damage to that membrane and we can pick up very readily on a urine test the amount of albumin in the urine. Over time many of our patients with CKD will get albumin in the urine, but there is a particular group of people where albumin occurs early. So if you have got diabetes, the first sign of damage to the kidneys isn’t on the blood test – so the creatinine level may be normal – but we see leakage through the kidneys into the urine of albumin.

So for people with diabetes for many years, we have been actually asking them to produce urine samples on at least a yearly basis because this is the early warning sign of kidney damage in someone with diabetes. We also know that there are people with hypertension, high blood pressure and other conditions who will also start to leak albumin in the urine, and these people need extra special blood pressure control because we know that by treating blood pressure better we can reduce the strain on the kidneys and we can reduce the albumin going through into the urine. So it’s a very, very useful test. It’s not always a test that patients like to do, because people forget, but it is really important. It is as or even more important for some people than doing the blood test. And every year we would like to see our patients, we do blood tests, we do urine tests and obviously we check their blood pressure.

So [pause] for many of our patients chronic kidney disease is not a single condition. It is part of other medical problems they have. So we might pick it up in someone who has already had a heart attack, in someone whose has had high blood pressure and someone with diabetes. We don’t need to do separate check-ups for chronic kidney disease on top of everything else. So ideally it should be possible for a patient to come to the practice and been seen about their medical problems as a whole rather than just focusing on one aspect. So perhaps as part of your blood pressure check you will be asked to have your blood pressure measured, you’ll have a blood test, we might also send your urine off to check your kidney function.

After you have had the test done then usually in my practice I would ask patients to contact the practice to see if I have left them a message about the results. Often the kidney function will be gradually declining. That is not necessarily anything to worry about. It’s the rate it is declining and the level it is at that matter. So I will perhaps leave them a message to say, Your kidney function is the same as before, so it is not normal but it is what it was for you and it’s not getting worse. I might say, The kidney function is a little worse, but that would, in many ways what I would expect as people get older. Sometimes I ask people to come back and see me to talk about it because it’s often very difficult on the telephone to get over these concepts and to understand the exact level. I can also print them off a graph. I can show them what’s actually been happening to their kidney function so that I think it’s important that you, visual images are very good to help you to see what’s happening. But I would expect the graph to show a small decline. Sometimes it will actually show things going up and down because kidney function can improve a little and it can decline a little. So it’s not a smooth graph. It would be moving up and down, and again that’s what I would expect and wouldn’t be anything to worry about.

So most of my patients I would see perhaps once or twice a year about their kidney function, unless their kidney function is in the lower levels. And when it drops below 30 we call that chronic kidney disease Stage 4, and those people would have more check-ups and would perhaps be expected to go to the hospital.

The people with kidney function between 30 and 60 I would expect can be managed most of the time by a GP and a practice nurse within a practice as part of the practice chronic disease management programme and with regular check-ups there. So there aren’t any specific issues other than the things that we do anyway, which is about treating blood pressure and about lowering risk of heart disease, and about lifestyle advice, all of these things we should be able to manage quite usefully in Primary Care.

I have to say that I would inform a patient if I feel that it is important for them to know. So my very elderly patients I may not necessarily tell them, but then of course they are the ones also who are at issue, who are at risk of acute kidney injury. But there are some patients who, who may not benefit from knowing, but for the majority of patients they will benefit from knowing and having that information.

We only have very short consultations in general practice. It’s often very difficult to cram it in, and sometimes people feel afraid or anxious about telling a piece of information that they feel is going to open up a whole catalogue of questions and information. So what I think, this is where I think patient information is so important. So I would like to be able to say to someone that, Weve have had a blood test. It does show that you have got chronic kidney disease, which means that you’ve had several blood tests over a period of time which show that your kidney function has declined. I would like to give them a simple explanation but also an information leaflet that they can take home with them, and then what I do is I print things off the computer and get people to come back, because they can’t take everything in and it, sometimes it is a bit of a shock and it is worrying, but I think if you can give them the information to read about, invite them to come back, then you’re answering questions not trying to deal with everything all in one go. And that’s how I would handle it. But were all different and we all do things in a different way. But for most of my patients I hope I will have told them and will have explained to them what the issues are, because if you understand the issues you realise it is not about dialysis, it’s about staying healthy for longer, and surely that’s what we all want.

We know that as we get older, particularly after the age of 40, kidney function tends to decline anyway, but there are other conditions that can make it decline slightly more quickly. Those are particularly high blood pressure and diabetes but there are obviously some other conditions that run in families, such as Polycystic Kidney Disease, people may take tablets or medicines that can have an effect on their kidneys, and there are inflammatory processes that can affect the kidneys. So there is a great long list of other conditions but for most of the patients that I see in my general practice they will have a declining kidney function which is related to either high blood pressure or diabetes and made slightly more by the fact that they are also getting older.

In most of my patients I would say that most, that they will have it as part of other conditions that they have. Largely because in general practice a lot of the people we have tend to be older, whereas if you work in hospital you will see a different group of patients. And here I work at the university, so some of my people with chronic kidney disease will have it because they’ve got, they were perhaps born with abnormal kidneys, or they’ve had a very destructive inflammatory process which affects their kidney function. They may have got, they may have had recurrent infections because the plumbing system for their kidneys didn’t work very well. So this, here I will see much more a different group of patients and they will have what we call Primary Kidney Disease, something which is just affecting the kidneys, whereas for my older patients it tends to be part of high blood pressure, diabetes, cardio-vascular disease, so they have other processes of affecting other parts of the vascular system.

So one of the issues is that we can actually plot and monitor how kidney function is declining by repeating the blood test on a regular basis, perhaps once or twice a year. And we can see that for most people kidney function will only decline at about 1 or 2% per year. And they will never reach the level at which they may need dialysis or transplantation. And we are talking there about levels less than 15%.

So you may have been told that you or your family member have got chronic kidney disease, and that’s quite a complicated term to take on board. It’s important to know that when doctors and nurses talk about chronic’ they mean a condition that’s been going on over a period of time. And with chronic kidney disease we are talking about a change in the kidney function for at least 3 months in time. Disease is an interesting concept that people worry about as well. Unlike one process that can affect the kidneys, for chronic kidney disease there are actually several of them that can cause the kidneys to work less well.