Abstract
Background Chronic kidney disease (CKD) affects approximately 10% of adults in England. Of these adults, approximately 1% progress to kidney failure with a significant impact on health-related quality of life and high healthcare costs. CKD is associated with increased cardiovascular disease risk. New therapies to improve outcomes highlight the need for effective risk stratification.
Aim To explore primary care teams’ views and experiences of CKD risk stratification.
Design and setting Qualitative interview and focus group study with GP practices in South England, South London, and Yorkshire.
Method Twenty-six semi-structured interviews with GPs, pharmacists, and practice nurses, and four focus groups (31 participants) with practice teams including clinical, administration, and management staff were undertaken between January 2024 and January 2025 across 20 practices, informed by normalisation process theory, using thematic analysis.
Results We identified four key themes: 1) awareness of diagnostic criteria and risk- stratification tools, 2) value of coding CKD and discussion of risk, 3) barriers to CKD risk stratification, 4) improving CKD risk stratification. Despite universal awareness of diagnostic criteria, there was low awareness of risk-stratification tools. Coding was perceived as valuable for health professionals but not for patients. Concerns included increasing patient anxiety and overmedicalisation. Time pressures and lack of incentivisation were perceived as key barriers. Improved healthcare professional education, guidelines, pathways, and technology/automation were highlighted as areas of potential improvement.
Conclusion Primary care awareness of CKD is high, but workload, time pressures, and concerns regarding patient anxiety/overmedicalisation may contribute to incomplete risk stratification. Refining processes and effective patient communication could improve care.
How this fits in
Chronic kidney disease (CKD) is a common long-term condition associated with increased cardiovascular disease risk. A small proportion of people with CKD progress to kidney failure and might be treated with dialysis or a kidney transplant, or may choose a more conservative symptom-based pathway. Effective lifestyle measures and drug therapies can reduce both kidney and cardiovascular risk but currently many people who may benefit are not offered risk-based advice and treatments. Primary care healthcare professionals had universal awareness of how to diagnose CKD, but low awareness of risk stratification, and concerns regarding overmedicalisation and how to communicate CKD diagnosis to patients.
Introduction
Chronic kidney disease (CKD) stages 1–5 affect around 10% of adults in England.1,2 Approximately 1% (around 8556 in 2023)3 will progress to kidney failure requiring kidney replacement therapy each year. It has a significant impact on health-related quality of life and also an economic impact. NHS treatment costs for CKD are over £6 billion per year, >3% of the overall NHS budget, with dialysis treatment costing around £34 000 per patient each year.4 The World Health Organization designated kidney disease a global health emergency in 2025.5
CKD is defined by the Kidney Disease Improving Global Outcomes (KDIGO) consortium as a persistent (>3 months) structural or functional abnormality in kidney function.1,6 Kidney disease is risk stratified using blood tests for kidney function (estimated glomerular filtration rate [eGFR]: G1 — normal or high, to G5 — kidney failure),6,7 and urine tests for kidney damage (urine albumin:creatinine ratio [uACR]: A1 — normal to mildly increased, to A3 — severely increased).7 As eGFR falls, and albuminuria increases, both cardiovascular disease and kidney failure risk increase. The kidney failure risk equation (KFRE) uses age, sex, eGFR, and uACR to provide a 5-year risk estimate of kidney failure, that is, renal risk in those with CKD stages 3–5.8 The UK National Institute for Health and Care Excellence (NICE) advocates that those with a 5-year KFRE score >5% should be considered for referral to secondary care.9 US data demonstrated less than half of patients meeting this referral threshold being seen in a nephrology clinic within the subsequent year.10,11 No similar UK data linking KFRE to nephrology review has yet been published. However, both KDIGO staging and the KFRE require both eGFR and uACR, and since withdrawal as a Quality and Outcomes Framework (QOF) indicator in 2014 uACR is only completed in around 50% of patients with CKD.12 People living with CKD are overall at greater risk of cardiovascular disease than of kidney failure, with uACR predicting cardiovascular risk.13
Optimal CKD management entails informed communication with patients with risk stratification to explain disease severity and its broader implications. Many patients with CKD have multimorbidity. Frailty, diabetes, hypertension, and obesity/metabolic syndrome can have an impact on disease and progression.
This study explored the views and experiences of primary care professionals and the wider GP practice team regarding CKD, including factors underpinning implementation of CKD risk stratification and management in primary care, and the complex mechanisms that influence how innovations are adopted, adapted, and sustained in practice.
Method
Design
This was a qualitative study comprising semi-structured online interviews with healthcare professionals and focus groups with whole practice teams (including healthcare professionals, administration and management teams, and unregistered professionals such as social prescribers and health coaches) recruited from Southern England (Hampshire, Isle of Wight, and Dorset), South London, and Yorkshire, to reflect rural, coastal, and inner-city populations.
The gender-diverse team comprised two research fellows with experience of conducting qualitative research, a GP clinical academic registrar, a GP registrar, two clinical academic GPs, a public health academic, an academic pharmacist, an implementation science expert, and a patient and public involvement (PPI) contributor. Core research team members held monthly meetings to review study progress, review interview data, and collaborate on data analysis. Additional separate analysis meetings were held with the PPI contributor.
This study is reported in accordance with the Standards for Reporting Qualitative Research.14
Participants and recruitment
GP practices were invited to participate via the National Institute for Health Research clinical research networks (now regional research delivery networks) in Wessex, South London, and Yorkshire. Study information invited primary care professionals to take part in an individual interview and/or the whole practice to take part in a focus group. Interviews explored healthcare professional individual experiences and perspectives of the barriers and enablers of CKD risk stratification in the clinical context. Focus groups, however, were conducted with members from the same GP practice to explore the collective perspectives of wider practice teams on processes involved in risk stratification, enabling identification of gaps and clarification of team roles and responsibilities. Healthcare professionals who participated in interviews were also eligible to join practice focus groups; however, this was minimised where possible. Focus groups were drawn from different areas, that is, rural, coastal, inner city (Dorset, Hampshire, and the Isle of Wight, South London, and Leeds) to include practices with a range of patient demographics, including age, ethnic diversity, and levels of deprivation.
Potential participants received an invitation pack containing study information and a consent form, and could choose to participate online or in person. In addition to written informed consent, interviewers obtained verbal consent before starting each interview or focus group.
Data collection
Separate interview and focus group topic guides drew on the existing literature and input from our patient collaborator. Topic guides (Supplementary Box S1) were informed by key domains from normalisation process theory (NPT),15 which provides a framework for identifying factors and processes likely to hinder or enable widespread implementation of new practices. They captured data on value and purpose (coherence), participant’s engagement (cognitive participation), the work involved (collective action), and appraisal work undertaken (reflexive monitoring). Interviews, and online focus groups, were audio-recorded using Microsoft Teams. In-person focus groups were recorded using an audio-recorder. Field notes were taken to capture the interviewers’ impressions and reflections, and any aspects not captured by the recorder.
Interviews lasted a median duration of 37 minutes (range 23–70 minutes). Focus groups lasted a median duration of 34.5 minutes (range 27–38 minutes) and were conducted during existing practice meeting timeslots. On finishing each interview or focus group, interviewees were offered a copy of their transcript and study findings, when available. Data collection stopped on reaching thematic saturation (that is, when themes were rich, well developed, and understood)16 and a rigorous, credible analysis in relation to our aims had been achieved.
Data analysis
All recordings were transcribed verbatim by a professional transcription company and any identifiable data removed. Thematic analysis17 was used to explore the data. Data collection and initial analyses proceeded iteratively (that is, coding started after the first few interviews and informed subsequent interviews). Interview and focus group transcripts were initially coded separately. Two lead authors (the first and second authors) read the transcripts repeatedly to achieve data familiarisation and then applied line-by-line coding. Codes were derived inductively from the data and grouped together to produce an initial coding frame by recognising meaningful repeated patterns and identifying key concepts in the data. Initial codes were reviewed and compared to identify any similarities and differences and a detailed coding manual created to ensure transparent and systematic coding. Interview and focus group data were compared and combined into overarching themes. Themes/sub-themes were discussed and iteratively developed in collaboration with the research team to ensure diverse inferences and data interpretation. A negative case analysis was undertaken, ensuring all data were carefully considered and reducing the chance of preferentially selecting data fitting any preconceptions.18 Although analysis was primarily inductive (data-driven), NPT guided interpretation through input from two authors (the third author and the sixth author) who have significant experience in NPT. Themes and sub-themes were reviewed, reassigned, and mapped against the four constructs of NPT (Supplementary Box S2). NVivo (version 12) was used to manage data, and to implement and record coding.
Results
Between January 2024 and January 2025, two researchers conducted 26 online interviews with GPs, pharmacists, and nurses and four focus groups (three in-person and one online) with GP practice teams including healthcare professionals, social prescribers, health coaches, and administration and management staff (31 participants in total). Participant characteristics are summarised in Table 1.
Table 1. Participant characteristics Key themes
We identified four key themes:
awareness of diagnostic criteria and risk-stratification tools;
value of coding CKD and discussion of risk;
barriers to CKD risk stratification; and
improving CKD risk stratification.
These themes, mapped to NPT constructs, are summarised in Figure 1. Themes and their associated NPT constructs are presented below with selected illustrative anonymised quotes (FG, focus group participants; P, interview participants).
Awareness of diagnostic criteria and risk-stratification tool (NPT: coherence)
Across the multidisciplinary primary care team, participants demonstrated a shared and consistent understanding of the diagnostic process for CKD. Interviewees described use of diagnostic blood and urine tests (eGFR and ACR) in keeping with guidelines, suggesting familiarity. Participants differentiated CKD from other chronic conditions through their recognition of its typically asymptomatic nature and the incidental way it is often identified. This differentiation (a key subcomponent of ‘coherence’ within the NPT framework) highlights that, although CKD is conceptually understood, it is often normalised as part of routine monitoring rather than as an active diagnostic focus:
‘So generally, it’s opportunistic. We have our chronic disease patients that are invited … to do a urinary ACR as well. So, they’ll be doing those annually … but generally it’s opportunistic.’ (FG3, female pharmacist)
Analysis of participants’ accounts suggested that CKD diagnostic activities sit within a broader framework of chronic disease management, but the process is largely driven by existing systems and opportunistic testing rather than proactive identification.
In contrast with the strong shared understanding of diagnostic processes, there was limited collective understanding (coherence) around CKD risk stratification. Few participants reported using formal risk-stratification tools, and awareness of existing instruments — such as the KFRE or the KDIGO risk grid — was low.
Although participants recognised the potential utility of such tools, their comments reflected uncertainty about how they fit within existing workflows and clinical priorities:
‘I can see how referring those patients early is important. Perhaps we can prevent some progression if we were risk stratifying a bit better those patients.’ (P16, female GP, ≥10 years in role)
Value of coding CKD and discussion of risk (NPT: cognitive participation)
Diagnosing and coding CKD in clinical systems was typically perceived as important and valuable to health professionals, mainly to ensure safe prescribing, but consistently felt to be less useful for patients:
‘When you’re coming to prescribing as a nurse practitioner, if I can see a diagnosis of CKD, I’m obviously going to be far more wary about what I’m prescribing … So I think for healthcare professionals, really important. For patients, not so much.’ (P3, nurse practitioner, ≥10 years in role)
This led to challenges around forming a clear value and purpose (‘coherence’), in securing engagement (‘cognitive participation’), and willingness to undertake the work involved (‘collective action’). Participants from across the multidisciplinary primary care team reflected on the potential to cause patient anxiety by coding/diagnosing early-stage CKD, especially in older people, and the risk of overmedicalising. Practitioners commonly described the language around CKD as challenging, easily leading to patient misunderstanding, anxiety, and concerns. They highlighted a lack of societal awareness around kidney health, and the common difficulties of informing patients of historical CKD coding of which they were unaware:
‘It’s generating workload, generating disease, not disease mongering, but disease pathologising of patients with a scary title. Lots of our patients, lots of anxiety out there, it’s unrecognised. Lots of health anxiety. Are we potentially feeding into that and causing some harm with marginal benefits? So, I guess that’s a potential barrier or driver for us not being not being as keen as we could be to code.’ (P22, female GP, ≥10 years in role)
However, some participants acknowledged the need for risk stratification to optimise care and they viewed coding, giving a diagnosis of CKD, and discussing risk of progression as an opportunity for health promotion:
‘When I started in general practice it was like, “Oh, your kidney function is not so good, don’t worry about it”, it’s not like that any more, obviously, or, “It’s just age related” … Whereas now, I think we’re much more actually, we can do something about it, we can modify your risks, we can ensure that okay, your kidney function may not be as good but actually, we can try and prevent you having some of the complications associated with that.’ (P16, female GP, ≥10 years in role)
Barriers to CKD risk stratification (NPT: collective action)
Time pressures in general practice and lack of incentivisation were key challenges to diagnosing and risk stratifying CKD. Across accounts, participants described finding coding CKD challenging as it was often done during reviewing results of patients they may not know personally. In UK primary care, results are often reviewed by a named GP or team lead, rather than the requester, to avoid delay in actioning results and allow prompt visibility to patients who often have access to their own results. This lack of knowledge of the individual patient contributed to challenges related to engagement in a coherent plan for prioritisation, reduced engagement (‘cognitive participation’), and influenced ‘buy-in’ (‘collective action’) that could limit meaningful patient outcomes. Participants articulated the complexity of what is required in each CKD consultation as a challenge:
‘Just how time-consuming it is, really. Even on an individual basis, if you’re seeing someone for a kidney disease, there’s so much to go through, it is just quite time-consuming … the consultation is quite time-consuming.’ (P8, female GP, ≥10 years in role)
Lack of incentivisation of coding, diagnosing, and risk stratifying CKD was another common perceived barrier to good care. Participants acknowledged that a lack of incentivisation fuels the concept that CKD is not as important as other incentivised diseases. The large number of patients with CKD, the lack of processes to risk stratify which patients to prioritise, opportunity within routine work, and cost-effectiveness concerns were highlighted. Lack of a clear risk-stratification process led to operational work during clinical encounters being fragmented. Without guidance on which patients to prioritise, clinicians faced challenges integrating risk stratification into routine consultations:
‘I mean kidneys literally are the forgotten organ as far as I’m concerned. There is no QOF indicators, there’s nothing hanging on it … my organisation has got 47 000 patients. When you start running things like searches on how do we stratify these patients or find the most important ones that we can start making a difference for, the numbers are humungous.’ (P9, female GP, ≥10 years in role)
Patient health literacy and ability/willingness to engage with suggested advice and management plans following a CKD diagnosis was highlighted in the focus groups. Healthcare professionals expressed concerns that some individuals may not engage with lifestyle measures or comply with medications for diabetes or blood pressure particularly when asymptomatic. This was a particular concern for those already known to be marginalised by existing models of health care, such as those living in areas of high deprivation, on benefits, with other long-term conditions, and minority ethnic groups — especially where there was already cultural hesitancy or mistrust of standard healthcare systems:
‘That’s not everyone at all, but it is a significant issue in an area of high deprivation because patients just don't … It’s very low down on their list of priorities to know what a kidney is, or when their kidneys are not working. They’ve got so many other things that they worry about more, like where are they going to sleep, how are they going to pay for their heating, that kind of thing.’ (FG1, female GP)
Improving CKD risk stratification (NPT: reflexive monitoring)
Mechanisms suggested to improve CKD care included: improved pathways, guidelines, education, testing processes, integrated technology/automation, incentivisation, and community-based clinics. Research studies and incentivisation for coding and risk stratifying (for example, established payments for prescribing statins for CKD) were described as an impetus for system-wide searches and increased coding.
Improved technology (such as point-of-care testing), automated diagnostic/coding support (for both identification and coding and risk stratification, for example, embedded KFRE scoring) included within results (for healthcare professionals), and associated signposting (for patients) were suggested to support coding and risk stratification, as ways of contextual integration within collective action:
‘I have no idea why EMIS [GP electronic clinical system, formally known as Egton Medical Information Systems] can’t do coding automatically and pull down data from the hospital [records] system in the same fashion. So, it’s really frustrating that we a go into the hospital for blood tests to pull them down to then be able to compare because, invariably, a lot of those will be missed. So, I think that it seems silly that IT [information technology] lets you down, really, in primary care still. It shouldn’t be really done by doctors or anyone else. It should all be automatic, so I think, yes, that the technology needs to be better definitely … I think AI [artificial intelligence ] technology, actually, in this scenario, I think it would be a huge benefit for patients.’ (P10, female GP, 6–9 years in role)
It was appreciated that CKD care could not be easily facilitated within the confines of a short and often reactive primary care appointment. In UK primary care, cohort clinics for long-term conditions, such as asthma and diabetes, with dedicated staff, such as advanced nurse practitioners or pharmacists, facilitate thorough and expert care. Creating dedicated primary care or community CKD clinics and specialist CKD health professionals was therefore commonly seen as a mechanism to provide additional resource, allowing time for effective discussion of risk and to encourage improved risk stratification and CKD care:
‘I think if we had … chronic kidney disease clinics, because we’re seeing more and more … we could get patients to think that, okay, chronic kidney disease is quite common, or it doesn’t shock them, and maybe make them more aware that chronic kidney disease is something that we see quite regularly in primary care and maybe we can deal with it via primary care.’ (P19, female pharmacist)
Education programmes and tailored patient resources, as for other long-term conditions such as diabetes, were seen as effective ways to deliver reliable information efficiently and support discussion of risk:
‘For our pre-diabetes patients, there’s a diabetes education programme they can do, there’s some information they can easily access about that. I’m not aware, and I could be wrong, that there’s anything really for CKD. If we could have somewhere we could easily signpost the patients and have a conversation with them but not having — if you don’t have the time to have an in-depth conversation, having somewhere to signpost them that they could go for that.’ (P16, female GP, 6–9 years in role)
‘Having culturally appropriate leaflets or information or even videos of people with lived experience of CKD of similar backgrounds, I think sometimes that’s more powerful than a conversation with a doctor.’ (P25, female GP, 6–9 years in role)
Patient and public perspective
This study sought to understand primary care staff views on the clinical and procedural aspects of risk stratification in primary care. In consolidating our conclusions we felt it would be useful to gain a patient and public perspective of the findings.
An online patient and public inclusion and engagement workshop was conducted with six primary care patients, carers, and members of the public, followed by an in-person workshop with 28 attendees, including charity representatives. Attendees were asked their perspectives on the findings of this study.
The group felt that giving information about CKD earlier would allay anxiety, by allowing them to take ownership of, and make informed decisions about, their own health, and to engage with lifestyle modifications. Patients and carers sought information on the internet, often leading to greater anxiety because of conflicting information. Patients reported the utility of peer support and kidney charities — yet these were not widely known about or signposted to from primary care staff.
Discussion
Summary
This qualitative research explored primary care healthcare professionals’ views on risk stratification for patients with CKD, through individual practitioner interviews and whole practice team focus groups. The application of NPT as the theoretical lens enabled identification and exploration of the variety of work and processes needed to successfully undertake CKD risk stratification in primary care.
Findings highlighted an absence of systematic approaches to CKD risk stratification. NICE diagnostic criteria were widely recognised, but CKD diagnosis was often opportunistic, and awareness of risk-stratification tools was low. In particular, a near universal lack of awareness of risk-stratification tools such as the KFRE led in turn to a lack of appreciation of the importance of uACR testing and overall risk stratification to inform patients and support evidence-based care — in turn leading to a lack of reinforcement to patients of the importance of this test. From the perspective of NPT these findings suggest limited coherence — although clinicians understood CKD as a clinical entity, its proactive identification and management were not fully conceptualised as routine work.19,20 Coding is known to improve care in both UK21 and European22 cohort studies; however, although our participants valued diagnostic coding for professional purposes such as safe prescribing, it was perceived as less meaningful for patients, particularly where concerns about inducing anxiety were prominent. These tensions indicate challenges in cognitive participation and collective action, as professionals negotiated competing priorities between patient-centred communication, avoiding overmedicalisation, and safety-driven administrative tasks.23
Practical difficulties of informing patients at the point of diagnosis, coupled with time constraints and prioritisation of coding, further illustrate incomplete normalisation of planned, relational care processes. Knowledge gaps and limited awareness of community resources were illustrative of limited collective action at the micro-level, where frontline teams lacked capacity to support patients effectively. Similarly, nursing teams acknowledged potential roles in promoting engagement with monitoring (for example, uACR) but reported inconsistent enactment, reflecting insufficient reflexive monitoring of team contributions.
We found organisational barriers, including lack of incentivisation and time, despite recognition of the alignment of CKD risk stratification with the NHS 10-year plan.24 Participants proposed leveraging existing frameworks for hypertension and diabetes management, and involving specialist nurses and pharmacists, suggesting attempts to embed CKD work within established systems — a key NPT mechanism for sustaining practice.25 However, these adaptations were contingent on resource allocation and organisational support to ensure collective action at a meso-level.
Policy ambitions to improve CKD prevention and management were evident, yet implementation was affected by long-standing systemic inequities of access and engagement, and workforce pressures. Persistent disparities in engagement among patients most at risk of CKD, such as those with low socioeconomic status, poor health literacy, and minoritised backgrounds, reflect health inequalities (NHS England, Core20PLUS5)26 and are compounded by limited availability of tailored resources. These findings emphasise the need for coordinated strategies that address structural determinants of health and provide adequate resourcing for primary care teams.
Our findings demonstrate that, although CKD risk stratification was recognised as clinically important, its integration into routine practice was hindered by gaps in coherence, cognitive participation, and collective action at the individual and organisational levels. An approach to improve testing, triage (risk stratification), and treating holistically has the potential to improve outcomes.
Strengths and limitations
This study explored the views of primary care staff towards the rapidly changing landscape of CKD guidance and management adding valuable new insights into individual- and system-level factors affecting care. Most people with CKD are cared for in primary care whereas much of the existing literature centres around people within secondary care clinics who have more severe CKD and established CKD diagnoses.
The study recruited in a few limited regions and interviews were likely to have taken place with more engaged practitioners and practices, which may limit generalisability. There may also be desirability bias in responses to interviews and focus groups.
Comparison with existing literature
A qualitative study in 201227 explored processes underpinning the implementation of CKD management in primary care through interviews with GPs and practice nurses. A predominant theme was healthcare professional anxiety about disclosure of CKD, especially in patients who were older,27 in keeping with findings from our study. A further qualitative study in 2015 explored GPs’ views of managing advanced CKD and again expressed a wish for better guidance around managing older patients with advanced CKD and comorbidities.28 The impact of non-disclosure of CKD in primary care on patient ability to self-manage has also been highlighted.29 A narrative review in 2024 described the UK primary care perspective of barriers and enablers to effective kidney care but did not directly seek to use qualitative research to explore these views.30
Since 2012, national endeavours such as the NHS England/UK Kidney Association Think Kidneys/Transforming Participation in Chronic Kidney Disease programme31 have aimed to raise the profile of kidney disease. The NHS England renal service transformation programme concluded in 2024 with the creation of eight regional secondary care-led renal clinical networks, with the goal of improving integrated care. However, the current study highlights that, although awareness of CKD and its importance is widespread in primary care, there are significant challenges in implementing risk stratification, and hence equitable access of novel evidence-based treatments.
Implications for research and practice
Our findings highlight four key opportunities providing opportunities to improve and better integrate CKD risk stratification into routine primary care practice:
increasing awareness and use of risk-stratification tools;
improving coding, risk stratification, and communication of risk;
recognising persistent barriers, particularly time constraints and limited financial incentivisation; and
emphasising the need for further research to refine and develop risk-stratification tools
The first of the key themes was increasing awareness and use of risk-stratification tools. Incorporation of structured teaching on CKD risk tools into GP training programmes and undergraduate medical curricula would further strengthen competency. At a local level, practices and primary care networks should implement targeted educational sessions to enhance recognition of CKD and promote routine use of KFRE in clinical decision-making. Resources for CKD education should be promoted. For example, the UK Kidney Association has developed dedicated educational resources for primary care professionals,32 alongside ongoing initiatives to embed the KFRE within laboratory and clinical information systems. Similarly, the Royal College of General Practitioners has produced a framework to support GPs to develop an extended role in kidney health.33
The second of the key themes was improving coding, risk stratification, and communication of risk. Emerging evidence from large cohort studies demonstrates that a proactive approach to CKD management improves both kidney and cardiovascular outcomes, and reduces environmental burden from CKD.34 Regular practice-level audits and systematic integration of risk discussions within long-term condition reviews could support more consistent implementation. Integrated care boards and NHS England clinical kidney networks should promote standardised CKD coding and support progress towards nationally defined targets.
The need for improved communication with patients and the public regarding CKD risk is increasingly urgent given the availability of evidence-based therapies — including sodium glucose co-transporter 2 inhibitors,35,36 glucagon-like peptide 1 receptor agonists,37 non-steroidal mineralocorticoid receptor antagonists,38 and disease-specific treatments,39 which, combined with established strategies such as statins and renin–angiotensin system inhibition, effectively slow CKD progression yet are not offered equitably to all who might benefit from them. Development and evaluation of tools to support clinicians in conducting CKD risk discussions, and communication of risk (such as EMPathicO),40 may help mitigate anxiety for both patients and healthcare professionals.
Although this study focused on the perspectives of healthcare staff, as there is a published literature documenting the views of patients with CKD (all the established cohorts are patients recruited from secondary care nephrology patient services),29,41,42 further research is required to understand the experiences and priorities of people with earlier-stage CKD, individuals at risk but not yet diagnosed, and those from underserved communities, including socioeconomically disadvantaged groups.
The third of the themes was recognising persistent barriers, particularly time constraints and limited financial incentivisation. Time pressures and the absence of specific financial incentives are barriers to systematic application of CKD risk stratification. However, the inclusion of CKD within strategies such as the NHS England Cardiovascular Disease Modern Service Framework,43 ‘Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association’,44 and the designation of CKD as a World Health Organization priority,5 will contribute to elevating CKD within clinical and commissioning agendas. Furthermore, alignment with overlapping incentive frameworks — such as those relating to lipid management, hypertension, and diabetes — offers opportunities to enhance care for individuals at risk of, or living with, CKD.
The final theme was emphasising the need for further research to refine and develop risk-stratification tools. Ongoing research is required to refine CKD risk-stratification approaches, particularly for earlier stages of disease where predictive accuracy remains limited. Developing tools validated specifically for primary care populations is essential, given that most CKD is identified and managed within this setting.
