Potential impact of NICE guidelines on referrals from primary care to nephrology: A primary care database and prospective research study

Abstract

Background: National Institute for Health and Care Excellence 2021 guidelines on chronic kidney disease (CKD) recommend the use of the Kidney Failure Risk Equation (KFRE), which includes measurement of albuminuria. The equation to calculate estimated glomerular filtration rate (eGFR) has also been updated. Aim: To investigate the impact of the use of KFRE and the updated eGFR equation on CKD diagnosis (eGFR <60 mL/min/1.73 m2) in primary care and potential referrals to nephrology. Design and setting: Primary care database (Secure Anonymised Information Linkage Databank [SAIL]) and prospective cohort study (UK Biobank) using data available between 2013 and 2020. Method: CKD diagnosis rates were assessed when using the updated eGFR equation. Among people with eGFR 30-59 mL/min/1.73 m2 the following groups were identified: those with annual albuminuria testing and those who met nephrology referral criteria because of: a) accelerated eGFR decline or significant albuminuria; b) eGFR decline <30 mL/ min/1.73 m2 only; and c) KFRE >5% only. Analyses were stratified by ethnicity in UK Biobank. Results: Using the updated eGFR equation resulted in a 1.2-fold fall in new CKD diagnoses in the predominantly White population in SAIL, whereas CKD prevalence rose by 1.9-fold among Black participants in UK Biobank. Rates of albuminuria testing have been consistently below 30% since 2015. In 2019, using KFRE >5% identified 182/61 721 (0.3%) patients at high risk of CKD progression before their eGFR declined and 361/61 721 (0.6%) low-risk patients who were no longer eligible for referral. Ethnic groups 'Asian' and 'other' had disproportionately raised KFREs. Conclusion: Application of KFRE criteria in primary care will lead to referral of more patients at elevated risk of kidney failure (particularly among minority ethnic groups) and fewer low-risk patients. Albuminuria testing needs to be expanded to enable wider KFRE implementation.