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Predicting risk is the new mantra for modern medicine. In ‘After Achilles’1 the challenge is set — in the maelstrom that is primary care, we need all the risk stratification tools we can get to help us identify who’s more at risk than the next person.
QOF encouraged us to identify chronic kidney disease (CKD), and now overburdened by its commonness, we are at risk of throwing away all we have achieved. Few diagnoses are predictably associated with such a dramatic increase in cardiovascular risk and none are so easily identified by a cheap and easily available blood test.2,3 The clustering of vascular pathologies with diabetes and hypertension makes this burden of disease the greatest challenge for the next generation of patients and doctors.
We investigated the reassurance given by NICE, that the previous decade’s CKD QOF initiative had improved the identification and management of CKD. In a practice population of 10 264, 9% of adults aged ≥18 years had a diagnosis of CKD on repeated testing. Despite this remarkable prevalence (usual estimates 3–6%), a total of 75% of these patients with CKD were unaware of the diagnosis, and in more than 25% both GP and patients were unaware of the condition. The results demonstrated that this lack of awareness was not limited to those with mild renal compromise but applied to one-third of patients with CKD stage 4. Our short intervention, either by phone or letter, significantly improved attainment of NICE (health indicator and education) criteria but also identified the continued confusion between CKD and lower urinary tract symptoms.
It’s time to remember why we estimated renal function in the first place. In a world of uncertainty, this is information for free. When associated with hypertension, diabetes, proteinuria, and vascular disease — pause — look again and feel confident that CKD means something. The lower the number the higher the risk.2,3