For Kidneys Sake
For Kidneys' Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS)
This podcast series aims to provide healthcare professionals, particularly primary care professionals, with accessible insights into kidney health.
Each episode offers bite-sized discussions on key topics such as chronic kidney disease management and heart failure and practical updates for improving patient care. With episodes just 15 minutes long, you can listen on your commute, during a break, or while out for a walk. Join us as we explore the latest advancements and strategies in integrated kidney care to empower clinicians and patients alike.
For Kidneys Sake
Pharmacists on the Frontline of CKD & CRM
The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).
In this episode of For Kidneys’ Sake, consultant nephrologists Prof Jeremy Levy and Dr Andrew Frankel are joined by Rory Donnelly, a senior pharmacist and system lead for diabetes and chronic kidney disease (CKD) in Hammersmith and Fulham. They discuss the expanding role of pharmacists in the management of CKD and the wider cardio-renal-metabolic (CRM) spectrum in primary care. Rory explains how pharmacists identify and review patients with CKD, optimise medicines, and provide education to support better self-management, while working closely with GPs and nursing colleagues.
The conversation covers practical challenges such as confirming a CKD diagnosis, interpreting changes in kidney function after starting treatment, and deciding when to adjust therapy for frail or elderly patients. The discussion also highlights newer treatments such as SGLT2 inhibitors and finerenone, and the ongoing importance of lifestyle advice and clear communication. The episode provides practical, evidence-based insights for pharmacists and clinicians supporting people with kidney and metabolic conditions in primary care.
Key Takeaways
- Pharmacists are central to CKD and CRM management – They lead medicine reviews, coding, and patient education within long-term condition care.
- Confirm CKD before diagnosis – Use previous results and trends in eGFR and ACR to ensure it is chronic and not an acute or temporary change.
- Individualise treatment – Clinical judgement should take priority over rigid guideline use, particularly for older or frail patients.
- Understand expected treatment effects – A modest fall in eGFR after starting ACE inhibitors, SGLT2 inhibitors, or finerenone is expected; monitor rather than stop treatment unnecessarily.
- Support lifestyle and self-care – Encourage healthy diet, regular exercise, and patient understanding that CKD monitoring aims to protect long-term kidney health.
Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE
Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)
The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.
The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.
Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub
Jeremy Levy
Hello, it's Jeremy Levy here, consultant nephrologist from Imperial College Healthcare NHS Trust.
Andrew Frankel
And I am Andrew Frankel, a colleague of Jeremy's, also work at Imperial College Healthcare NHS Trust, and welcome to another of our podcasts in the series for kidney sake. And we are really delighted today to be joined by Rory Donnelly. Now Rory is a senior pharmacist who works in GP practices. He's a site lead pharmacist for a very large urban primary care practice in our locality. Shepherd's Bush here in West London but is also the system lead for diabetes and CKD across Hammersmith and Fulham. Welcome to For Kidneys Sake Rory.
Rory Donnelly
Thank very much both of you. Yeah, really delighted to be here. I've been listening to your podcasts and found them fantastic and useful. And obviously, an ulterior motive is to get some signed merchandise. Here's to hoping.
Jeremy Levy
Rory will find something for you, I'm sure.
Andrew Frankel
Well. I'm also owed another t-shirt so we'll see how things go. It's really nice of you to say you've enjoyed the Now before we lose any GP's practice nurses or patients listeners switching off today and deciding not to listen, this episode is actually critically important for all our normal visitors and listeners. You all may or may not know that in primary care practices in the UK,
It's now quite commonly pharmacists who review the lists of patients with chronic diseases including CKD, diabetes and hypertension. They check they're on the best possible and correct medicines and review the treatments and their rationale with the patients themselves. So in this episode we want to review what pharmacists actually do, what they are thinking about the challenges they faced and the commonest questions want answered in relation to Cardiomel metabolic disease and CKD. All in our usual bite-sized 20 minutes. So if you're not a pharmacist, this will help you understand what they are doing and how and so that you can support them. And if you are a pharmacist, well, we'll solve all your problems.
Jeremy Levy
So I'm out there fixing their punctures, solving their childcare, fixing their dishwashers. I'm not doing all of that. But yes, we're getting all of that. So we hope that you'll stay and listen. And this is a really big workforce. So Rory was telling me earlier that, for example, in five large practices in Hammersmith, there are 20 pharmacists working on chronic disease management. This is a massive change in the last few years in terms of the professional staff doing a lot of this work. So Rory, I'm going to kick off. Let's get you into this.
Can you actually tell us what is your role? What's your role in managing patients with these chronic diseases, chronic kidney disease, cardiorenal metabolic syndromes, hypertension, all overlapping with diabetes of course. And of course your role might be different from other pharmacists specifically, but what do you actually do?
Rory Donnelly
Yeah, thank you. So Jeremy, before I mention my role within our primary care network.
It's worth noting that pharmacists roles in general practice do differ greatly. So I'm very lucky. I work at one site with multiple pharmacists, whereas some might be the opposite. So it could be covering different practices, multiple different practices across the week, which of course poses its challenges. So across our PCN in West London, I'm the co-lead for diabetes and CKD. So working collaboratively with GP, pharmacy, nursing colleagues to ensure all the contractual targets are achieved. More importantly, we sort of focus delivering high quality care so patients are well managed and the best possible treatment. So in relation to CKD that'd mean that anyone with potential CKD is identified, reviewed, appropriately coded and informed and worked up as needed. All patients with established CKD receive an annual review. Patients optimise the maximum tolerated therapy so in line with current guidelines and each patient is counselled about their CKD. So what does that mean for their health, the steps they can take to improve their outcomes.
Jeremy Levy
That's a lot of work isn't it? When you actually decide you want to make changes, you've seen a patient, identified them essentially from your computer and you want to change their prescriptions or do something, how do you mostly contact patients?
Rory Donnelly
Yeah, so good question really. guess it depends on the patient and their situation. So mean, pre-COVID, the majority of consultations were face-to-face, but obviously that's now switched to more remote telephone consultations with the benefit of access for patients to get health care easier. I'd say it's a mix, ideally face-to-face, to really enforce kind of CKD counselling and disease education, potentially get a urine dip when you see them and put in front of you. The caveat of, like I said, it's the ease for patients for accessing remote consultations.
We'd always contact newly diagnosed CKD patients, so that would either be with a phone or face to face. If we've seen them for number of years and they're nice and stable, we might just give them a telephone call. Always safety netting them with the wonderful guidance that you guys have put together from Northwest London.
Andrew Frankel
That's really helpful to understand the role and what you do and how you do this. But let's now tackle some of the actual challenges and problems pharmacists in particular face. So Rory, what are these?
Rory Donnelly
Yeah, of course. So, kicking off really, so one major issue we worry about is being sure that someone with a slightly low EGFR or a raised urine protein or an existing label of CKD actually has chronic kidney disease. And we're not missing potentially another problem, another acute problem. And if it needing any more diagnostic tests, pharmacists need to be confident they're managing just CKD and not missing something else.
Together with of course the associated sort of cardio, renal, metabolic issues over lipids, blood pressure and diabetic control. So simply, how are we sure that CKD is just CKD?
Jeremy Levy
It's a really important question, Rory. A lot of this is about confidence and actually we talked about this in our episode three. Go and listen to it, guys. Our first series and it was called, Chronic is Not Wicked. And it is often about changes over time. So if someone had a GFR, let's say 52 years ago, and now it's 45 or 42, then you know it's not an acute problem. They already had a slightly impaired.
Kidney function two years ago and it's slightly worse now. So in that circumstance, it's definitely not an acute problem. Yes, it's dropping, but it's not new. And actually in primary care, most people with a raised urine albumin crackling ratio, the ACR, or a low EGFR will often have one of those other syndromes, diabetes, overt cardiovascular disease, long-standing hypertension. And it's very likely that that is causing chronic kidney damage because they've got a combination of renal ischemia or hypertensive damage or diabetic damage. So serial changes, have they got sort a systemic syndrome that will include ischemia, hypertension, et cetera? And then finally, if you didn't have any previous results at all, it's much harder. And so if you've got somebody with no previous results, either a urinary ACR or an EGFR, and you've now got one-off results with a low EGFR or a raised urinary ACR, then it really, really is important not to just label them with CKD. Have they had a urine dipstick to look for blood and protein? Because if there's blood and protein in the urine, actually you've got to think about other things as well. Those patients might well need a renal ultrasound to make sure they have got two kidneys and they look normal. And then again, it is about that serial data. So a repeat early blood test for the EGFR especially, but it's not an emergency, but over the next couple of weeks, let's say, would be really important because if it's falling, again, not a chronic problem, there's something else going on. But again, an EGFR that's slightly low and then sustained over time is likely to be chronic. So there you are, it's gonna be mostly about are there previous results to look at?
Rory Donnelly
Excellent, thank you. I think the major issue for us balancing is for pharmacists in particular, I'm sure other healthcare professionals as well, is for balancing guideline recommendations and maximising obviously potential important therapies against increasing age of patients. So pharmacists are neat and tidy people, we're very good at following guidelines, but when should we not? And should we also be using the kidney failure risk equation in older patients?
Jeremy Levy
Wow, lots in there, Rory. And you're absolutely right, agree. Pharmacists are fantastic at following guidelines. And Andrew and I might occasionally think that you're too good sometimes. So that is actually a really good question. When not to do it? And your knowledge of the KFR, either, kidney failure risk equation, that's staggering. Well done, brilliant. So, that first bit about when not to follow guidance. And we talked about this in our first series, actually episode 12, managing kidney health in older adults versus frailty. Really good episode.
Jeremy Levy
I think it's about reflecting the patient in front of you. And this can be hard if you don't know the patient and if you're just reviewing a list or a register. But a completely for 80 year old with, let's say, CKD 3BA3. So let's say an EGFR of 42 and a bit of proteinuria ACR of 50. But they're playing golf twice a week. They're cycling every day. They're fit and they've got 15 years of life expectancy ahead of them and so they want to remain free not just of progressive kidney disease but of cardiovascular deaths and an early death. fit 80 year old should be on maximum dose ACE or and an SGLT2 inhibitor and have excellent blood pressure control. But they're not the same as a frail 80 year old with exactly the same EGFR and urinary ACR who's in a care home who can only walk with a frame with early cognitive impairment or dementia. And that person, that 80 year old, that second one, I wouldn't want them started on a new medicine such as an SGLT2 inhibitor. The guideline won't separate those two. It will just say EGFR and ACR start the medicine. But that early polyuria, for example, from dapaglifozin may cause this slightly confused frail person in the care home to fall over. If they do get a urinary infection, it might be a problem.
And there's going to be no absolute benefit. Their life expectancy is much lower. So I think it's really about the patient in front of you. And pharmacists shouldn't be concerned that they're not starting drugs, certainly in that second circumstance. So in elderly people, it is about balancing the person in front of you and whatever you know about them. It's going to be really, really important. These new drugs are stopping progression to end stage kidney disease, but they are also reducing risk of all death and of cardiovascular disease. But again balance it with the person in front of you. And then your second question was all about this KFRE, the kidney failure risk equation, which is a really useful tool, but don't forget, it gives you the risk of renal failure in the next two or five years, but only renal failure. And the competing risk is death. And if you're 80 years old, you might have a low risk of kidney failure because you're gonna die from something else. So again, it's balancing those two things. And that's what you need to bear in
Rory Donnelly
Thank you so much, Jeremy, that's very helpful. So another issue is what to do when patients are already on maximum dose of RAAS inhibition and an SGLT2 inhibitor. For example, a 50-year-old man with a previous heart attack, no diabetes, CKD3BA3, but there's still significant proteinuria. Let's say the ACR was previously 120 and now treated is around about 60. So what are we meant to do now? What do we do with that ACR? Are we happy with that?
Andrew Frankel
Well, that's another great question Rory and it does cause a lot of anxiety in pharmacists and also to myself as a clinician. This is a relatively young man who still has significant residual risk despite the fact that you have treated them appropriately and we are seeing this more often.
So what do you do? Well, you do need to ensure that the blood pressure is properly controlled, i.e. it's less than 130 over 80, that they're on a statin to reduce cardiovascular risk. It's really important to ensure that you've talked to them about activity and exercise and a healthy diet. But at this time, there are no other medicines available or needed they on the best treatment. These treatments may not make proteinuria vanish but a 50 % reduction is still a good response. So you can reassure the patient that all is as good as it can be. The reduction in ACR is excellent and they will continue to be monitored annually. And then of course the other important point is listen out carefully on the literature and the podcast because there will be future treatments coming along the line.
Rory Donnelly
That's super helpful, Andrew. We just need the confidence to know we've done all we can and there's nothing else to add.
Okay, so what if we are talking diabetes? Our current hot topic is finerenone When should we add this medicine and to who?
Jeremy Levy
I'm gonna leave that to Andrew as well, he knows all about finerenone
Andrew Frankel
Yes, so well in fact we should have been clear that the example you gave in your last question was not a person with diabetes and this is an example of where I said new treatments are coming down the line. Well this is a new treatment that is available. Finerenone is a new form of mineralocorticoid receptor antagonist, it's a version of spironolactone but it is different and has different effects and it has beneficial effects in relation to reducing cardiac and reducing kidney risk, particularly in people with diabetes. So currently, NICE has recommended adding to fineronone to people with diabetes with their GFR between 25 and 60, if they are already on either an ACE or an ARB and an SGLT2 inhibitor or intolerant to one of those agents and they still have that residual risk. So if that patient you described in the previous question, that 50 year old man had diabetes, he would be entirely appropriate for fineronone You do need to make sure that the potassium is less than five. And this will reduce the risk of kidney failure or death significantly further. So it is worth the polypharmacist for that patient. Currently, what we are doing in North West London and I know this does vary around the country. We are starting in secondary care with a potassium check at around 3 to 4 weeks and then after 6 months supply of treatment primary care can take over the continuation of this medication. I should point out we do also see a small drop in GFR which can be like when you add an ACE or an Arb up to 30 % and as I've said a small rise in potassium.
Rory Donnelly
Again, really helpful, thank you. So linked to that actually, and other medicines, the issue of serum creatinine rising and EGFR fall when we start a RAAS inhibition or SGLT2 inhibitor or finerenone So when do we need to get worried? Pharmacists can get anxious about missing things, but don't want to worry patients or booking for any extra or unnecessary tests. So, or bring a huge list of concerns to GPs when this is an expected issue. So what do we do about repeat EGFRs after starting these new therapies.
Andrew Frankel
Yeah, this is a great question and I want to just say one thing that I think is important to understand which is that I see people all the time, that's my job, starting on RAAS inhibitors with CKD, having a variety of different rises or changes in GFR. In primary care you see this less often and I think that's why it sometimes becomes more worrying. So a figure about 30 % is really important because if there is a change in GFR of around 30 % you do need to hold the medicines and review. It doesn't mean that you're stopping and they can never take it, it's about that review. When you're reviewing you should ensure that the patient does not have another contributing factor to the declining kidney function. They could be using additional agents such as non-steroidals.
If they are on diuretics they may have been over diareased and a bit dry or we could have reduced their blood pressure too much as a consequence of the optimisation. A drop of between 25 or 30 is OK but should probably still prompt the review but the finerenone or the Acer Arb does not need stopping. In that case though, when it's 25 to 30
It's worth repeating the kidney function in another 4-6 weeks to see if the decline has continued or stabilised. If there is stability, I would then recommend just continuing with the optimisation and monitoring in the future. They've reached a new baseline, they should continue to be stabilised and it should only stop the RAAS and finererone if the decline continues further.
Rory Donnelly
Again, thank you. Yeah, it's just that confidence isn't it with dealing with that drop and being happy it's within sort of acceptable limits. So thank you. A common question we get from patients when reviewing their CKD or potentially new CKD diagnosis is what can they do without taking medications and what can they do to reverse their CKD or diabetes or hypertension?
Jeremy Levy
That's not you get just just you rather Rory gets those questions. Andrew and I get this all the time. Nobody wants to take medicines if they can help it. And more and more people just want to try other things. However hard we persuade them. But it is really, really important. And we've talked about that before. We've had an episode on lifestyle and cardiovascular disease. That was episode seven and lots around education for patients. We've just done an episode on exercise. We both know how important exercise is.
Here in North West London, we run education for patients that's called Know Your Kidneys and out there there's loads around diabetes. So these are very important things, the things you can do without drugs. So we wanna talk to people about the standard remit of a healthy lifestyle. There's nothing very special about CKD, chronic kidney disease, or cardiorenal metabolic syndromes. It's a standard healthy diet, minimising processed foods, relatively low in meat, relatively low in salt, more plant-based, and then that
banging on about exercise, trying to aim for people to get more and more active, aiming to do 150 minutes a week. And it's a mixture, aerobic, resistance, weight bearing, but whatever people can fit around their lives. So really, really encouraging all of that. And that really matters. It really helps improve prognosis, reduce cardiovascular risk, reduce progression of kidney disease. And then we are almost always going to add medicines. It will rarely be enough, but those are really important things to do.
And you might well see blood pressure drop, urine ACR drop with all those lifestyle measures. And that's really reassuring for a patient. The caveat would be when patients mention some herbs and going out and buying supplements, we just discourage that almost always. Almost all of those herbs or supplements do more harm than good and no evidence for any benefit.
Rory Donnelly
And we do get some pushback when we talk with patients when they have a new label in the record saying CKD and they can get anxious or angry not told this before and this can be challenging as well.
Andrew Frankel
Yes, we hear this a lot too from primary care and we have actually covered this also in one of our previous sessions. But the key is to explain that this is not a new disease they have, but an important way that we can make sure that they are regularly monitored and on the best possible treatment to avoid them coming to harm in the future. And what we're trying to do is to prevent the kidney function getting worse over time. And it is because everyone has got so much better in primary care at identifying these individuals, screening them and coding them that we are seeing more people being recognised with CKD.
Rory Donnelly
So two more quick questions from me actually. So what about low level proteinuria? What do we do about it? So say for example ACR in the 20s, what do we do with it?
Jeremy Levy
I'm grabbing this one Andrew, I'm going to fight you over this question. So first of all Rory, you go and listen to episode 16 of our first series of podcasts which is all about low level proteinuria. What does it mean? But the bottom line is it is telling us there's some early kidney damage but it's not urgent. You don't need to phone the patient in the middle of the night and go round to an emergency department. So it's giving us an early sign of early kidney damage which needs review of all cardiovascular risks, review of their hypertension, their diabetes.
It's a chance to educate patients to stop things getting worse, but it's not a panic. And it may not need medicines if it's that low level, depending on quite what the precise level, but it is that opportunity to start to do things to prevent things deteriorating.
Rory Donnelly
Yeah, thank you. think it's a recurring theme, really isn't it around confidence with dealing with especially with abnormal blood tests, not abnormal enough to limit panicking and starting new therapies and as you say, good gateway into counselling the patient and things. And finally for me, heart failure and CKD. So I know we're meant to ignore the kidneys, but again, it's like confidence abounds, you we're adding in furosemide or creatinine rising when we start the pillars of heart failure treatment and what do we do with that?
Jeremy Levy
We never want you to ignore the kidneys Rory, but that was exactly right. That was in this instance exactly the right thing to do in treating heart failure. And I thought we put it very well. Ignore the kidneys. You ignore the change in GFR of creatinine. Now, if you start to the good quality treatment for heart failure, which might include diuretics if they're symptomatic, but the main pillars, creatinine will rise and GFR will drop a little bit. But in the long run. Having a stronger heart is beneficial for the kidneys. And again, we had a whole dedicated podcast, The Heart Failure and Chronic Kidneys in season one, go and listen. And one of my heart colleagues, I love this phrase, called it permissive hypercreatinemia, meaning allowing the creatinine to rise when you treat the heart failure. So yeah, in that instance, only that instance, ignore the kidneys.
Andrew Frankel
Yeah, I love that Jeremy. I do have to stop this now. It's been a great discussion. So Rory, for our three take home messages, let's just hear from you. What are the things that you think are the three take home messages?
Rory Donnelly
Thank you both, it's been fantastic and it's really hard just to pick three things. I think the three that stand out for me though, so number one, think confidence that CKD is just CKD and being able to manage that and being happy that it's not something else. Number two, think patients on maximum dose RAAS inhibition, SGLT2 inhibitors that may still have continued raised ACR are actually on the best treatment and nothing to add. And number three, it's around the use of finererone and CKD and diabetes. So growing patient cohort that I'm sure we'll see more of.
Andrew Frankel
Thank you very much Rory and before we sign off, one of the things I do want to do is to thank all the pharmacists who working in primary care, who doing so much work to help to improve the care of people with CKD.
Jeremy Levy
Yeah, I agree, Andrew and Rory. Thank you so much for joining us today. I think that's been useful. I hope you think it's been useful. And I've learned lots about the challenges you face. So thanks very much.
Rory Donnelly
Thank very much.
