Skip to main content

06-06-2018 | Nephropathy | Article

General practitioners’ perspectives on management of early-stage chronic kidney disease: a focus group study

Journal: BMC Family Practice

Authors: Carola van Dipten, Saskia van Berkel, Wim J. C. de Grauw, Nynke D. Scherpbier-de Haan, Bouke Brongers, Karel van Spaendonck, Jack F. M. Wetzels, Willem J. J. Assendelft, Marianne K. Dees

Publisher: BioMed Central



Guideline adherence in chronic kidney disease management is low, despite guideline implementation initiatives. Knowing general practitioners’ (GPs’) perspectives of management of early-stage chronic kidney disease (CKD) and the applicability of the national interdisciplinary guideline could support strategies to improve quality of care.


Qualitative focus group study with 27 GPs in the Netherlands. Three analysts open-coded and comparatively analysed the data. Mind-mapping sessions were performed after data-saturation.


Five themes emerged: defining CKD, knowledge and awareness, patient-physician interaction, organisation of CKD care and value of the guideline. A key finding was the abstractness of the CKD concept. The GPs expressed various perspectives about defining CKD and interpreting estimated glomerular filtration rates. Views about clinical relevance influenced the decision-making, although factual knowledge seems lacking. Striving to inform well enough without creating anxiety and to explain suitably for the intellectual ability of the patient caused tension in the patient-physician interaction. Integration with cardiovascular disease-management programmes was mentioned as a way of implementing CKD care in the future. The guideline was perceived as a rough guide rather than a leading document.


CKD is perceived as an abstract rather than a clinical concept. Abstractness plays a role in all formulated themes. Management of CKD patients in primary care is complex and is influenced by physician-bound considerations related to individual knowledge and perception of the importance of CKD. Strategies are needed to improve GPs’ understanding of the concept of CKD by education, a holistic approach to guidelines, and integration of CKD care into cardiovascular programmes.

Trial registration

Not applicable.
de Zeeuw D, Hillege HL, de Jong PE. The kidney, a cardiovascular risk marker, and a new target for therapy. Kidney Int Suppl. 2005;(98):S25–9.
Roderick PRM, Mindell J. Prevalence of chronic kidney disease in England: findings from the 2009 health survey for England. J Epidemiol Commun H. 2011;65(Suppl I):A12.CrossRef
Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298(17):2038–47.CrossRefPubMed
Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351(13):1296–305.CrossRefPubMed
Fox CS, Matsushita K, Woodward M, Bilo HJG, Chalmers J, Lambers Heerspink HJ, et al. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis. Lancet. 2012;380(9854):1662–73.CrossRefPubMedPubMedCentral
Matsushita K, van der Velde M, Astor BC, Woodward M, Levey AS, de Jong PE, et al. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet. 2010;375(9731):2073–81.CrossRefPubMedPubMedCentral
Mahmoodi BK, Matsushita K, Woodward M, Blankestijn PJ, Cirillo M, Ohkubo T, et al. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without hypertension: a meta-analysis. Lancet. 2012;380(9854):1649–61.CrossRefPubMedPubMedCentral
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Inter Suppl. 2013;3:1–150.CrossRef
NICE Clinical guideline: Chronic kidney disease. Early identification and management of chronic kidney disease in adults in primary and secondary care. London: National Collaborating Centre and National Institute for health and care excellence; 2008. September (last modified 2014)
De Grauw WJC, Kaasjager HAH, Bilo HJG, Faber EF, Flikweert S, Gaillard CAJM. Landelijke transmurale afspraak chronische nierschade. Huisarts Wetenschap. 2009;52:586–97.CrossRef
Allen AS, Forman JP, Orav EJ, Bates DW, Denker BM, Sequist TD. Primary care management of chronic kidney disease. J Gen Intern Med. 2011;26(4):386–92.CrossRefPubMed
Lenz O, Mekala DP, Patel DV, Fornoni A, Metz D, Roth D. Barriers to successful care for chronic kidney disease. BMC Nephrol. 2005;6:11.CrossRefPubMedPubMedCentral
Van Gelder VA, Scherpbier-De Haan ND, De Grauw WJ, Vervoort GM, Van Weel C, Biermans MC, et al. Quality of chronic kidney disease management in primary care: a retrospective study. Scand J Prim Health Care. 2016;34(1):73–80.CrossRefPubMedPubMedCentral
Crinson I, Gallagher H, Thomas N, de Lusignan S. How ready is general practice to improve quality in chronic kidney disease? A diagnostic analysis. Br J Gen Pract. 2010;60(575):403–9.CrossRefPubMedPubMedCentral
Blakeman T, Protheroe J, Chew-Graham C, Rogers A, Kennedy A. Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study. Br J Gen Pract. 2012;62(597):e233–42.CrossRefPubMedPubMedCentral
Abdel-Kader K, Greer RC, Boulware LE, Unruh ML. Primary care physicians' familiarity, beliefs, and perceived barriers to practice guidelines in non-diabetic CKD: a survey study. BMC Nephrol. 2014;15:64.CrossRefPubMedPubMedCentral
van Dipten C, van Berkel S, van Gelder VA, Wetzels JF, Akkermans RP, de Grauw WJ, et al. Adherence to chronic kidney disease guidelines in primary care patients is associated with comorbidity. Fam Pract. 2017;34(4):459–66.CrossRefPubMed
Walker D, Myrick F. Grounded theory: an exploration of process and procedure. Qual Health Res. 2006;16(4):547–59.CrossRefPubMed
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.CrossRefPubMed
van Gelder VA, Scherpbier ND, van Berkel S, Akkermans RP, De Grauw IS, Adang EM, et al. Web-based consultation between general practitioners and nephrologists, a cluster randomized controlled trial. Fam Pract. 2017;34(4):430–6.CrossRefPubMed
Marshall MN. Sampling for qualitative research. Fam Pract. 1996;13(6):522–5.CrossRefPubMed
Simmonds R, Evans J, Feder G, Blakeman T, Lasserson D, Murray E, et al. Understanding tensions and identifying clinician agreement on improvements to early-stage chronic kidney disease monitoring in primary care: a qualitative study. BMJ Open. 2016;6(3):e010337.CrossRefPubMedPubMedCentral
Vest BM, York TR, Sand J, Fox CH, Kahn LS. Chronic kidney disease guideline implementation in primary care: a qualitative report from the TRANSLATE CKD study. J Am Board Fam Med. 2015;28(5):624–31.CrossRefPubMedPubMedCentral
Lo C, Teede H, Ilic D, Russell G, Murphy K, Usherwood T, et al. Identifying health service barriers in the management of co-morbid diabetes and chronic kidney disease in primary care: a mixed-methods exploration. Fam Pract. 2016;33(5):492–7.CrossRefPubMed
Matsushita K, Coresh J, Sang Y, Chalmers J, Fox C, Guallar E, et al. Estimated glomerular filtration rate and albuminuria for prediction of cardiovascular outcomes: a collaborative meta-analysis of individual participant data. Lancet Diabetes Endocrinol. 2015;3(7):514–25.CrossRefPubMedPubMedCentral
Pang J, Grill A, Bhatt M, Woodward GL, Brimble S. Evaluation of a mentorship program to support chronic kidney disease care. Can Fam Physician. 2016;62(8):e441–7.PubMedPubMedCentral

Be confident that your patient care is up to date

Medicine Matters is being incorporated into Springer Medicine, our new medical education platform. 

Alongside the news coverage and expert commentary you have come to expect from Medicine Matters diabetes, Springer Medicine's complimentary membership also provides access to articles from renowned journals and a broad range of Continuing Medical Education programs. Create your free account »