Professor Gene Feder

Brief Outline: Professor Gene Feder explains how treatment in primary care for cardiovascular conditions will benefit kidney health, how GPs can support their patients in controlling their blood pressure and improving their lifestyle. He also talks about GPs’ attitudes towards guidelines on kidney health.

Background: Gene Feder is a GP in Bristol and Professor of Primary Care at the University of Bristol. His research interests include the management of cardiovascular risk and conditions in general practice and the health care response to domestic violence and abuse. He has chaired NICE guidelines on these topics.

More about me...

Gene Feder is a GP in Bristol and Professor of Primary Care at the University of Bristol. His research started with a doctoral thesis on the health and health care of Traveller gypsies. This was followed by studies on the development and implementation of clinical guidelines, the management of chronic respiratory and cardiovascular conditions in primary care and the health impact of domestic violence and abuse. His current research programmes focus on the diagnosis and management of cardiovascular conditions and health care responses to domestic violence and abuse. His main methodological expertise is in randomised controlled trials and systematic reviews. He collaborates with epidemiologists and social scientists on cohort and qualitative studies respectively.
Professor Feder has expertise in cardiovascular health, in particular the diagnosis and management of angina and using cardiovascular risk as a basis of treatment decisions. He also is an expert on domestic violence, in particular the response of health care professionals to survivors of partner abuse. His expertise in clinical guidelines and quality of health care has focused on the validity of guidelines and their implementation in primary care. He has chaired four UK national guideline development groups.

Professor Gene Feder explains that if a GP is already treating a person’s cardiovascular system then that will also protect the kidneys.

Now people who have heart disease, or coronary heart disease as it's called, have blockages in the arteries in the heart and they also have a higher risk of having blockages in the arteries going to the brain and to the kidney. So it's part of a more general – what’s called vascular condition, and there are specific treatments that can help prevent further damage. But if you don’t know that the kidneys are involved that treatment may not be as specific.

Now the truth is that really good treatment to prevent another heart attack, or indeed to prevent the first heart attack if you're at high so-called cardiovascular risk is fundamentally, would also, will protect your kidneys and that means specifically keeping your blood pressure at a relatively low level, which sometimes requires drug treatment. So you could argue that if a GP is looking after their patient with diabetes and raised- or raised blood pressure or high cardiovascular risk properly for those problems, there isn’t much additional that they can really do in relation to the kidneys. Which is one of the reasons why GPs, up till now, have not necessarily emphasised that there may be a reduction of kidney function to their patients because if they're already doing all the right things - the patient doing all the right things and the GP doing all the right things to prevent further complications, say, from high blood pressure or diabetes - then that is also going to protect the kidneys.
 

Professor Gene Feder explains that patients and their GPs both have a role in protecting kidney health; he talks about the support that general practices can offer patients in changing their lifestyle.

So the specific patient objectives is, or are, to do with what we already know about weight, exercise, not smoking. All of those factors protect your kidneys as well; improve… in a sense the blood flow to the kidney by preventing blockages to those blood vessels, and they also then help prevent stroke and heart attack. So those are the key, you know, patient contributions. The GP contribution is really around appropriate medication, and the biggest risk of the kidney is from raised blood pressure.

So prescribing appropriately, prescribing the right medication – there a number of different families of anti… of blood pressure lowering drugs, and choosing the right ones needs to take into account what's happening to the kidney as well.

The other contribution that the GP can make is looking at the other parts of cardiovascular risk such as your cholesterol, your lipid profile as it's called, which needs to be treated if that’s abnormal, or needs to be treated if you’ve already had a heart attack or stroke and that actually also benefits the kidney. So it's a partnership between the things that the patients can do and the things that the GP can recommend.

And you mentioned that patients can do good things for their kidneys, for their kidney health by watching their diet, their weight and stopping smoking. What kinds of support could patients expect from their GP's surgery in helping them make those changes?

So it's supporting patients for behavioural change and I guess I'd put smoking at the top of the risk list. I mean, that’s part of the Duty of Care of the general practice. So many practices discharge that duty by having a practice nurse or a nurse practitioner who is particularly experienced at giving advice and support to patients. In relation to smoking cessation there now are very good nicotine replacement methods which, there is an additional benefit to talking about them and getting support and not just buying them across the counter. So a practice needs to be set up to give that support around smoking cessation; how to prescribe the nicotine replacement and needs to be in a position to give good advice on exercise; good advice on dietary choices. That should be part of modern general practice and, in my view, is just as important and there's some evidence for this, as prescribing the right medication.
 

Professor Gene Feder talks about the kind of conversation that GPs and patients with CKD should have about the pros and cons of taking blood pressure lowering drugs to reduce risks of future health problems.

So the question about how we can encourage and support patients to take medication really comes down to having the ability to explain and to discuss the, if you like, the trade-offs and risks and benefits of taking medication because I think as doctors we sometimes assume that if we recommend it that it'll happen, and we know that’s not the case. So I think the right method is having an honest conversation about the benefit of the drugs, which may not be as much as the doctor assumes, and so making that explicit and having a conversation about what taking an additional medication might be in reducing the risk say of a heart attack or a stroke.

What the additional benefit might be in terms of preventing further decline of kidney function – that needs to be part of a conversation. The patient may decide that actually it's not worth taking that additional drug for an additional say, you know, five percent reduction in their ten year risk of a heart attack or stroke and that to me seems a very legitimate decision on the patient's part.

I think one of the challenges here is that, for the majority of patients who have reduced kidney function, the effect of that isn’t a substantially increased risk of kidney failure down the line later in life. In fact the majority of patients don’t have an increased risk of kidney failure. The effect of their reduced kidney function is an increased risk of heart attack and stroke. So it becomes part of that larger conversation that we have for any patient who, say has raised blood pressure and doesn’t even have any issues with their kidney, about “is it worth taking this drug because you're feeling perfectly healthy Mr Smith, for the next twenty/thirty years depending how old you are, in order to reduce your risk of a heart attack or stroke by X percent?”. And that is the crux of the conversation because people with reduced kidney function aren't ill, any more than someone with raised blood pressure is ill, any more than someone at an increased cardiovascular risk is ill. These are healthy people. It's just that they do have an increased risk of a problem down the line and that has to be the content of a conversation. GPs are used to having that conversation because it's not how we were historically trained but actually it's where we have to be now and , so my hope is that patients who do have blood tests and urine tests showing protein which suggest that they have reduced kidney function, are able to have that kind of conversation with their GP before making a decision about taking medication.
 

Professor Gene Feder talks about GP attitudes to the original NICE guidance on CKD and that he believes the 2014 update has improved on the original.

In the last ten years, as there’s, you know, been raised awareness of CKD and the pulling in of monitoring for CKD and its diagnosis in GP guidance, and indeed the Quality and Outcomes Framework, which is what has a very strong influence on what GPs do, there was a push back from GPs because of a perception that we were over-diagnosing patients and that we were taking, if you like, perfectly healthy patients who had some degree of um kidney function abnormality - and I’m putting it like that because a lot of this was based on blood tests alone - and one of the big improvements in the new guidance is it really highlights the importance of checking for protein in the urine and that being part of making a diagnosis of chronic kidney disease.

Whereas before – and this may have been ignorance just on the part of us GPs – there was an ambiguity about that and we were getting results back from the laboratory based on the blood test, like the creatinine or the glomerular filtration rate calculation, which put the patient in a- in a category, potentially in a category of CKD - when in fact there wasn’t any evidence that treating that or managing that would make any difference to that patient. So it seemed from a GP perspective a sort of spurious labelling of patients, which was often the reason why GPs did not mention it to their patients as well.

And unfortunately they then mixed into that patients who had reduced kidney function and leaking protein, so there was a sort of blurring of the boundaries. And I think that that caused the GPs to – not – let’s put it diplomatically - not to prioritise the issue of CKD. I do think with the new guidance there is a real focusing on those patients who do potentially have a problem, and where there is some evidence that managing it, particularly through blood pressure, is going to make a difference.

So this reaction on the part of GPs to over-diagnosis and if you like over-medicalisation of normal variation will I hope be a thing of the past. But it’s a challenge to general practice to try and respond appropriately to this problem. And I guess to temper the enthusiasm of specialists. And this is not just true for kidney specialists - all specialists are really enthusiastic about what they do. All specialists are worried about failure to diagnose, and that’s true if you’re an oncologist or a heart specialist or a stroke specialist or a kidney specialist. So general practice is a place where things are missed. And there is pressure on GP to not miss, and unfortunately that sometimes gets translated into a pressure to over-diagnose. And so GPs have this important role of trying to temper – to temper that enthusiasm. And I think the new NICE guidelines strike a good balance between the sort of- the generalist and the specialist perspective.
 

Dr Gene Feder explains why in some circumstances GPs may decide not to inform their patients about a mild kidney impairment.

Now historically GPs sometimes didn’t even communicate to patients that there was any reduction in their kidney function and I think the reason for that was because they felt, “well we're not going to do anything different for this patient; we're still going to treat their blood pressure, we're still going to give them advice say on cardiovascular prevention”. So why give the patient that additional information about their kidneys when there's, in a sense, nothing to be done about it. And when I think in the minds of many of us GPs, we thought, 'Well you know this is just another risk factor and not one that we would directly try and treat.' Now things have moved on a bit I mean in various ways and one way is that I think GPs just have to be more transparent about what they're doing. And therefore I think patients can now expect that GPs will signal to them that there's some problem about their kidney function but put into the context of really how much risk that involves and whether indeed it needs any treatment at all or whether it can simply be monitored over the years.

And so could you imagine some circumstances where maybe telling a patient that their kidney function is impaired might not be in the patient's best interest?

The short answer to whether it's ever in the patient's best interest not to tell them that their kidney function is impaired is “no”. I think that the issue here is complicated by the fact that if your blood test shows that your kidney function is a bit impaired but you're not leaking any protein, that actually you shouldn’t have the label of CKD – chronic kidney disease – and the new NICE guidelines is very clear about that. So one could argue that, for those patients who, in a sense, get the all clear because they're retaining the protein fine in their kidneys but their blood test shows a slight lowering of function, that that doesn’t need to be communicated, and that’s debateable I think because in an era where patients are encouraged to have access to all their tests and to their records it would raise a concern if the GP didn’t actually explain that. And I think this all part of the sort of …strategy of being transparent and giving appropriate information. Where the information needs to be more detailed is where there's definite evidence of CKD, where there is protein loss and the blood test shows a reduction of function. And then I think, you know, one needs to give quite a lot of detail.