Chronic Kidney Disease in Primary Care: Small Changes That Make a Big Difference

Chronic kidney disease (CKD) is common in primary care, but it’s often easy to miss. Patients don't often come in with complaints about CKD.

Instead, it usually shows up in routine blood tests, annual diabetes check-ups, hypertension clinics, or cardiovascular risk assessments. It can feel like another result to code, another QOF target to meet, or another box to tick; however, over the past few years, the evidence has fundamentally changed how we should think about CKD.

If I had one key message to primary care clinicians, it would be this: don’t think of CKD as a kidney disease, think of it as a cardiovascular disease with renal manifestations. Once we make that shift, our conversations with patients, our prescribing decisions and our follow-up all begin to look different.

CKD is common, but progression is not inevitable

Around one in ten adults has evidence of CKD, and prevalence rises dramatically with age. Most patients won't need dialysis or a transplant, but they face a higher risk of heart disease, hospital stays, and early death. In fact, many patients with CKD are far more likely to die from a cardiovascular event than progress to kidney failure. That is why early identification matters.

Primary care has the unique opportunity to detect CKD long before symptoms develop.

We see patients regularly for:

• diabetes reviews

• blood pressure monitoring

• medication reviews

Each encounter is a chance to spot at-risk patients and act before serious harm happens.

One of the biggest lessons I have learnt is that we should avoid focusing solely on the estimated glomerular filtration rate (eGFR). An isolated eGFR value provides only part of the picture. A patient with an eGFR of 58 mL/min/1.73m² and no albuminuria may have a different outlook than another patient with the same eGFR but with significant albuminuria. Too often, albuminuria remains under-investigated despite being one of the strongest predictors of renal and cardiovascular outcomes.

Albuminuria changes everything

I would encourage every primary care clinician to adopt this:

• Check the urine albumin-to-creatinine ratio (ACR) whenever you are assessing or monitoring CKD.

This sounds simple, but in everyday practice it is frequently missed.

Albuminuria is more than just evidence of kidney damage; it is an independent marker of cardiovascular risk. Patients with elevated ACR are more likely to experience myocardial infarction, stroke, heart failure and progressive CKD than patients with reduced kidney function alone.

The KDIGO 2024 guideline reinforces the importance of combining eGFR and ACR to stratify risk, rather than relying on kidney function in isolation. The familiar KDIGO heat map is a key tool in primary care. It quickly shows which patients need closer monitoring or stronger treatment.

Whenever I review a patient with CKD, I mentally ask three questions:

1. What is their eGFR trend?

2. What is their ACR?

3. What is their overall cardiovascular risk?

Those three questions often tell me far more than a single laboratory result.

New therapies have changed the landscape

Perhaps the biggest change in CKD management over the past five years has been the emergence of sodium-glucose co-transporter-2 (SGLT2) inhibitors.

Large studies like DAPA-CKD and EMPA-KIDNEY showed that medications initially developed to treat diabetes have shown to do more. They significantly slow down CKD progression, reduce cardiovascular events, and lower hospital visits. This is true for many patients, even those without diabetes. This is one of the most important developments in nephrology for decades.

For primary care clinicians, we now have treatments that truly change the course of CKD instead of just managing its effects. The challenge remains as recognising these eligible patients.

I often find that patients with CKD remain on older treatment regimens despite now meeting criteria for therapies that offer significant renal protection. Annual medication reviews are a great chance to check if patients can benefit from SGLT2 inhibitors. This is especially true when optimising ACE inhibitors or ARBs as needed.

Of course, these medications require sensible counselling. Patients should know about the risk of genital infections, the need to stay hydrated, and when to pause treatment during acute illness. A simple “sick day rules” discussion can prevent unnecessary complications and empowers patients to manage their treatment safely.

Blood pressure remains one of our most powerful interventions

Although new therapies receive much of the attention, excellent blood pressure management remains an effective way to slow CKD progression. The evidence has been remarkably consistent over many years.

Achieving blood pressure targets reduces progression of kidney disease and substantially lowers cardiovascular risk. Yet many patients remain above target despite multiple consultations.

In my experience, this often reflects therapeutic inertia rather than clinical complexity. Patients become accustomed to blood pressures sitting just above target because everyone is understandably busy and small elevations can seem relatively unimportant. However, over years, those seemingly modest differences accumulate.

Rather than asking whether today’s blood pressure is “acceptable”, I find it more helpful to ask:

• “Is this the best blood pressure we are likely to achieve safely for this patient?”

That small shift in thinking can lead to better medication, home monitoring, or lifestyle talks that might not occur otherwise.

Medication reviews matter more than we think

CKD should trigger a medication review every time. Many commonly prescribed drugs require dose adjustment as kidney function declines. Equally important is identifying medications that may contribute to acute kidney injury. Non-steroidal anti-inflammatory drugs remain an important example. Many patients continue purchasing ibuprofen over the counter without recognising the potential impact on kidney function.

Simple conversations can prevent avoidable harm.

Using risk rather than numbers

One development I think deserves greater adoption in primary care is the Kidney Failure Risk Equation (KFRE). Historically, referral decisions were often based on arbitrary eGFR thresholds. We now know that patients with the same kidney function can face very different risks of worsening.

The KFRE uses age, sex, eGFR, and albuminuria to predict the chance of needing kidney replacement therapy in the next two to five years. Using risk prediction helps us find patients who need nephrology reviews. It also reassures those with stable conditions that they can stay under primary care safely. It also provides a much more meaningful framework for discussions with patients.

Patients understand risk.

They often find it hard to understand an eGFR of 52. However, they know their risk of kidney failure in the next five years is very low. Also, they see that extra treatment could greatly lower that risk.

Communication is often the missing intervention

One aspect of CKD management that receives minimal attention is language. Many patients feel anxious when they learn they have “chronic kidney disease.” This is especially true if they link kidney disease to dialysis. Others dismiss the diagnosis entirely because they feel well. Neither response is particularly helpful.

I have found it useful to explain to patients that "the kidneys act as one of the body’s filters and that, while some decline in function can occur with age, our aim is to preserve kidney health for as long as possible". I emphasise "that protecting the kidneys also protects the heart and blood vessels."

This shifts the conversation away from frightening terminology towards prevention.

Patients become more engaged when they understand why we are checking urine samples, adjusting blood pressure medication or recommending newer therapies.

Primary care makes the biggest difference

Nephrologists rightly manage advanced kidney disease, but the greatest opportunity to improve outcomes lies much earlier.

Primary care teams identify CKD first. We monitor progression. We optimise cardiovascular risk. We review medications. We educate patients. We decide when specialist referral is appropriate.

None of these interventions is particularly dramatic. Together, they can delay kidney failure, lower cardiovascular events, and improve the quality of life for thousands of patients.

The best part of managing CKD is that effective care is based on simple principles.

• Measure both eGFR and ACR.

• Optimise blood pressure.

• Use evidence-based therapies, including SGLT2 inhibitors where appropriate.

• Review medications regularly.

• Communicate clearly with patients and use risk prediction to guide referral rather than relying on a single number.

CKD may be silent, but our interventions do not need to be. Small, consistent actions taken in primary care can have lifelong benefits for our patients. As evidence grows, primary care's role is more important and rewarding than ever.