In the daily work of general practice, where every consultation must balance efficiency with accuracy, one parameter is often overlooked yet could transform cardiovascular risk management: the assessment of chronic kidney disease (CKD). At the 25th World Organisation of Family Doctors (WONCA) World Conference 2025, held recently in Lisbon, Portugal, a session of the European Primary Care Cardiovascular Society (EPCCS) emphasized how this omission systematically underestimates risk in millions of patients.

Hidden Burden of CKD

“Chronic kidney disease is a major problem,” said Raj Thakkar, general practitioner specializing in cardiovascular disease and president of the UK’s Primary Care Cardiovascular Society. “It is a significant cardiovascular risk factor that we should not ignore, either in primary or secondary care.”

The figures Thakkar presented were striking: CKD prevalence far exceeds that of heart failure or diabetes, yet the condition remains underdiagnosed. In the UK, CKD prevalence is projected to rise by 34% by 2040 compared with a 50% increase in the prevalence of heart failure and 60% increase in that of atrial fibrillation.

Richard Hobbs, president of EPCCS and professor of general practice at the University of Oxford, Oxford, England, broadened the perspective: “Cardiovascular disease is the leading cause of death, premature death, and disability — and disability is what drives healthcare spending. If we don’t reduce events, we increase costs.”

Diagnostic Error That Costs Lives

The central issue, experts argued, lies in an incomplete diagnostic approach that relies solely on kidney function measured through estimated glomerular filtration rate (eGFR), while ignoring albuminuria. “You can have a normal eGFR and still have CKD,” Thakkar explained. “If you don’t check the albumin-to-creatinine ratio (ACR), you’ll miss the diagnosis.”

According to 2012 data presented by Hobbs, CKD was independently associated with 7000 excess strokes and 12,000 excess myocardial infarctions in a single year in the UK’s National Health Service.

Even more concerning is that research has shown CKD without diabetes raises the risk for heart failure, myocardial infarction, stroke, peripheral artery disease, and death more than diabetes without CKD. “This should convince us all not to ignore chronic kidney disease in our patients,” Thakkar stressed.

Risk Map Doctors Don’t Use

To properly classify patients, experts recommend the KDIGO risk map, which combines eGFR and ACR to stratify the risk for mortality, end-stage renal disease, and hospitalization for heart failure. “Raise your hand if you use this chart,” Thakkar asked the audience. Only a few hands were raised, underscoring the issue. “I’d like all hands to go up next time,” he added, stressing that the tool is essential for accurate risk assessment.

Diabetes poses a particularly complex challenge as specific pathophysiological mechanisms can mask kidney damage. Nicholas Jones, professor of general practice at the University of Oxford and member of the EPCCS, explained that in diabetes, upregulation of SGLT2 receptors in the proximal tubule increases glucose and sodium reabsorption.

“This fools the macula densa, which senses reduced renal perfusion and triggers vasodilation of the afferent arteriole, pathologically increasing eGFR,” Jones said. “You can be falsely reassured by a normal blood value in diabetes — and by the time eGFR drops to 60, the patient may already have lost about 80% of nephrons.”

New Therapeutic Frontiers

Diagnosis is critical as new therapies have recently transformed cardiometabolic-renal risk management. Jones highlighted results from the BaxHTN trial, published in The New England Journal of Medicine. The study investigated baxdrostat, a highly selective aldosterone synthase inhibitor: “In patients with uncontrolled or resistant hypertension already taking two or three drugs, baxdrostat lowered systolic blood pressure by nearly 9 mm Hg compared with placebo,” he said.

On the lipid front, treatment strategies are becoming increasingly personalized. “The latest European guidelines consider both lipid levels and long-term cardiovascular risk,” Jones told Univadis Italy, a Medscape Network platform. “So even if a patient has relatively low calculated risk but high lipid levels, they may still be eligible to begin treatment.”

Experts emphasized a clear message: A proactive approach is needed, not a reactive one. “We must find these patients and use the data in our health systems to ensure they are properly managed,” Thakkar said.

Correct coding in electronic health records emerged as another crucial factor. A 2017 UK audit showed that patients with CKD who were not formally coded were more likely to experience cardiovascular mortality and hospitalization because they were not managed effectively.

“You can set aside traditional risk scores if the patient has CKD,” Thakkar added. “We now know they are automatically at high risk for cardiovascular events. Every one of those patients should receive therapy for their cardiovascular risk factors since we cannot directly treat CKD.”

Gender and Ethnic Disparities

The discussion also underscored gender disparities in CKD management. Data from the UK CVDPREVENT audit showed that women are treated less effectively and less intensively than men, with physicians more likely to prescribe lipid-lowering therapy to men.

Thakkar noted that inequities extend to ethnicity as well. “If you are South Asian and have diabetes, you are 10 times more likely to develop end-stage kidney disease compared with your Caucasian peers.”

Message for Clinical Practice

The session concluded with a strong message for general practitioners: CKD is common, high-impact, underdiagnosed, poorly coded, and undertreated. “If we proactively identify these patients — especially by using ACR — we can prevent cardiovascular events,” Thakkar summarized.

Experts called for a shift beyond the traditional reliance on eGFR alone and toward comprehensive assessments that always include albuminuria. Only then can patients at risk be correctly identified and offered appropriate care to prevent avoidable cardiovascular events. Most will require combination therapy with antihypertensives and lipid-lowering agents titrated to the lowest achievable levels.

“The pandemic taught us that patients with poorly managed cardiometabolic and renal disease had the worst COVID outcomes,” Hobbs concluded. “Age was a major factor, but after age, the critical predictor of severe disease and death was cardiometabolic-renal disease.”

Hobbs declared receiving occasional funding for consultancy, research, or presentations from AstraZeneca, Bristol Myers Squibb, Bayer, Boehringer Ingelheim, Novartis, and Pfizer. Jones reported receiving consultancy funding from OXON Epidemiology, the British Heart Foundation, Wellcome Trust, and NB Medical Education. He declared having no conflicts of interest relevant to the topic. 

This story was translated from Univadis Italy.