How people with diabetes can prevent kidney complications
A new report has highlighted the “dialysis timebomb” and suggests that it is everyone’s responsibility to prevent kidney disease.
By Dr Zoe Markham-Lee and Swati Bhagat-Jones, MCSP of Kidney Research UK.
To help slow the impending crisis of kidney disease in the UK, there are multiple ways to support research and patient care. A key aim is to prevent as many people with diabetes and cardiovascular disease as possible from experiencing kidney failure and slowing chronic kidney disease (CKD) progression.
Kidney Research UK asks all those involved in the management of patients living with multiple long-term conditions, including kidney disease and diabetes, to:
● Ensure all people with diabetes are receiving the 8 care processes, with a focus on improving urinary ACR test rates to effectively monitor kidney disease risk and progression.
● Ensure access in primary care settings for all healthcare workers to utilise the “Primary care hacks” for up-to-date information on pathways to aid in identification and interventions for CKD.
● Through primary care services, provide patients with tools to help manage their own conditions, including diabetes and kidney health information prescriptions and accessible, informative content (such as the Kidney Research UK video on urinary ACR testing).
● A resource page with information for healthcare professionals can be found here.
In 2023, 30,000 people in the UK relied on dialysis to stay alive. Based on projections, as many as 143 000 people could need dialysis by 2033, meaning existing NHS capacity would need to grow by almost 400% to meet essential demand.
Diabetes is a leading cause of end-stage kidney failure. Almost one in three people with diabetes will go on to develop kidney disease, and 18% of patients requiring dialysis have diabetic nephropathy as the primary identifiable renal disease in the UK (UK Renal Registry, 2024).
More than 7 million people are already living with kidney disease in the UK. This is over 10% of the population, and the figure is expected to rise to 7.6 million by 2033. People living with diabetes, high blood pressure, cardiovascular disease and obesity are at particular risk of developing kidney disease, and the number of people with these conditions is increasing (Kidney Research UK, 2023).
Current guidelines on managing diabetes and kidney disease
People with diabetes and high blood pressure, who are therefore at risk of developing kidney disease, are principally managed in primary care. This creates an opportunity to intervene and prevent progression to kidney disease through management of blood pressure, cardiovascular risk and lifestyle factors. NICE guidelines state that testing for chronic kidney disease (CKD) should be carried out in at-risk populations, including those with diabetes, cardiovascular disease and hypertension.
The results of these eGFR and urinary ACR tests can be utilised to evaluate risk and code CKD accordingly, and both measures should be carried out and recorded as part of the 8 key care processes for people with diabetes.
A useful review that identifies barriers and enablers to the effective detection, diagnosis, disclosure and management of CKD in primary care has been published by Dr Stuart Stewart, a GP and Kidney Research UK-funded researcher undertaking a PhD in Epidemiology, available here.
The “3 within 3” concept
The London Kidney Network (2024) has developed guidance for care optimisation in people living with type 2 diabetes and CKD after reviewing multiple NICE guidelines. The concept of “3 within 3” highlights three key actions to take within 3 months of diagnosis to save lives.
These actions involve initiation of RAS/RAAS blockade in month 1, followed by SGLT2 inhibitor treatment (according to NICE guidance) in month 2, and a further blood pressure agent, if required, in month 3. More information here.
To support this concept, GP Kevin Fernando, alongside other primary care and renal consultants, has presented the “Primary care hacks” which detail the methods for both identification of CKD in primary care and CKD interventions in primary care according to the available recommendations and guidance.
The Kidney Failure Risk Equation is a validated tool, recommended by NICE (2021). When inputted into the risk calculator, the results from both eGFR and urinary ACR tests determine the 2-year and 5-year risk of treated kidney failure (dialysis or transplantation) for patients with CKD stages 3a to 5. This equation allows for robust discussion between healthcare professionals and patients, and allows personalisation of treatment.
Urinary ACR testing – The missed diabetes care process
The latest National Diabetes Audit suggests that, depending on location, only 16.3–56.3% of people with type 1 diabetes, and 26.1–63.0% of people with type 2 and other diabetes types, were receiving all 8 care processes for diabetes management (NHS England, 2023). These results present an opportunity to address health inequalities and to utilise resources to minimise the risk of complications associated with diabetes.
Urinary ACR testing levels dropped dramatically after their removal from the Quality and Outcomes Framework in 2015/16 (Stewart et al, 2024). The levels of ACR testing, as with the other care processes, dropped during the COVID-19 pandemic but, importantly, rates still have not recovered to pre-COVID-19 levels, with only 49.8% of people with type 1 diabetes and 60.7% of those with type 2 and other diabetes receiving urine ACR testing in England and Wales (NHS England, 2023).
What are charities doing to help?
As the leading funder of renal research, Kidney Research UK offers grants for both clinical and non-clinical research opportunities to transform the lives of those living with kidney disease. Kidney Research UK is keen to fund research in primary care and encourage earlier diagnosis of kidney disease.
Kidney Research UK published Kidney disease: A UK public health emergency in 2023. This report sets out the current health-economic implications of kidney disease and provides projections to 2033. It provides clear evidence that kidney disease should be a priority for governments and the NHS, and calls for implementation of specific healthcare interventions to save lives.
The report also demonstrates the potential impact of earlier diagnosis, equitable access to healthcare and better management of kidney disease, including the use of SGLT2 inhibitors. It estimated that the combined impact of all these interventions could reduce the number of deaths by 10,495 over the 10-year period. Additionally, were the suggestions in the report to be fully implemented, more than 2500 cardiovascular disease (CVD) events would be prevented (Kidney Research UK, 2023).
Research grants in primary care
Kidney Research UK is keen for healthcare professionals working within primary care to apply for our available research grants. Primary care professionals have a critical role in making kidney health equal for all and are uniquely placed to gather and analyse insights at a community level to drive change in mLTC research. More information on available grants can be found on our website, and we welcome suggestions for research through our open-door policy.
This feature is an extract from an article recently co-published in Diabetes & Primary Care and the Journal of Diabetes Nursing, reproduced with kind permission of the authors. Read the report in full here
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