For Kidneys Sake

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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)

Is dialysis always the best option for someone with kidney failure – or could it sometimes do more harm than good? 

For older, frailer patients living with advanced chronic kidney disease, the decision to start or continue dialysis is rarely straightforward. While dialysis can be life-saving, it can also bring significant physical, emotional and practical burdens, without necessarily extending life or improving its quality. In this episode of For Kidneys Sake, consultant nephrologists Prof Jeremy Levy and Dr Andrew Frankel are joined by specialist nurse Sister Ginny Prout from Imperial College Healthcare NHS Trust to explore conservative kidney management, supportive care and the importance of advance care planning. Together, they challenge the assumption that dialysis must always be the default treatment and explain why choosing not to dialyse can be a positive, clinically appropriate and patient-centred decision.

Drawing on her experience of speaking with nearly 500 dialysis patients and their families, Ginny shares practical insights into having sensitive conversations about frailty, deteriorating health, treatment preferences and end-of-life care. The discussion explores how to introduce advance care planning without causing unnecessary anxiety, how to manage differing opinions within families, and why effective communication between renal teams, GPs and palliative care services is essential. The team also highlights the value of London's Universal Care Plan in ensuring that patients' wishes are understood and respected across healthcare settings. Above all, this episode reinforces a vital message for healthcare professionals: good kidney care is not simply about prolonging life or improving blood results, but about listening to patients, respecting their priorities and helping them live as well as possible.

5 Key Takeaways

1. Dialysis is not always the best option for frail, older patients. For people with advanced kidney disease, significant frailty and multiple comorbidities, dialysis may offer little or no survival advantage while adding considerable treatment burden. Conservative kidney management should be presented as a valid, positive treatment option rather than a failure to treat.
2. Advance care planning conversations are often welcomed by patients. Healthcare professionals may worry about causing distress by discussing deterioration, resuscitation or end-of-life preferences. However, Ginny's experience demonstrates that patients frequently appreciate sensitive, unhurried conversations that acknowledge their individual circumstances, fears and priorities.
3. Conservative kidney management means active, supportive care – not doing nothing. Managing symptoms, reducing distress, maintaining comfort and preserving quality of life remain central priorities. Appropriate symptom control and access to palliative care are essential, even when dialysis is not being pursued.
4. Communication and shared decision-making are critical. Patients, families, renal teams, GPs and other healthcare professionals need to work together, particularly when treatment preferences differ. Advance care planning may require several conversations, and tools such as the Universal Care Plan can help ensure decisions and wishes are accessible across healthcare settings.
5. Treat the person, not just their kidney function. In advanced kidney disease, particularly among older and frailer patients, decisions should be guided by the individual's overall health, functional ability, personal values and goals. The focus must shift from simply treating declining kidney function to helping patients maintain dignity, autonomy and the best possible quality of life.

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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub 

Do you have a question? Send it now...

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)

Could stopping a diuretic to protect kidney function actually make a patient more unwell?

In this episode of For Kidneys Sake, Dr Andrew Frankel and Dr Jeremy Levy tackle common misconceptions about diuretics in chronic kidney disease (CKD). They explain why diuretics are used to treat high blood pressure and fluid retention, why a small change in kidney function during treatment is not always a reason to stop, and why thiazide diuretics can still work when kidney function is reduced.

They also share practical points on choosing between thiazide and loop diuretics, responding when fluid retention persists, and adjusting treatment as a patient’s weight and swelling change. Throughout, they stress the importance of sodium restriction and monitoring kidney function, electrolytes and weight, especially when higher doses or combinations of diuretics are needed.

Five takeaways

1. Diuretics do not generally cause CKD to progress, though excessive fluid loss can cause acute kidney injury.
2. Thiazide diuretics can still help control blood pressure in people with advanced CKD.
3. Loop diuretics are usually more effective for fluid retention; the episode explains why furosemide may need more than one daytime dose.
4. Persistent swelling calls for a review of sodium intake and treatment. Combining diuretics can be effective, but needs close monitoring.
5. Follow weight, symptoms, kidney function and electrolytes during treatment, and reassess the dose as fluid overload resolves.

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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub 

Do you have a question? Send it now...

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)

Could controlling potassium be the key to giving more patients the heart- and kidney-protective treatment they need?

High potassium can prevent people with chronic kidney disease or heart failure from receiving optimal doses of ACE inhibitors, ARBs and other RAAS inhibitors. In this episode of For Kidneys Sake, Jeremy and Andrew examine updated NICE guidance that lowers the potassium threshold for starting sodium zirconium cyclosilicate, better known as Lokelma, from 6.0 to 5.5 mmol/L in eligible patients.

They explore what this change means for primary care, including who may benefit, what to check before prescribing and how to start, adjust and monitor potassium binders. Most importantly, they explain why lowering potassium is not the ultimate goal: it is about enabling patients to receive the medicines that protect their hearts, preserve kidney function and improve long-term outcomes.

Five key takeaways

1. The Lokelma threshold has changed. Eligible patients may now start treatment when their potassium is persistently at or above 5.5 mmol/L.
2. Potassium binders are enabling treatments. Their purpose is to make it possible to start, continue or increase heart- and kidney-protective RAAS inhibitors.
3. Primary care can initiate Lokelma. Treatment may be started following advice from secondary care, which does not always require a face-to-face appointment.
4. Check before prescribing. Confirm the potassium result, exclude pseudohyperkalaemia, review contributing medicines and provide appropriate dietary guidance.
5. Do not stop once potassium improves. After controlling potassium, review and optimise the patient’s ACE inhibitor, ARB or other appropriate RAAS inhibitor—that is where the main long-term benefit lies.

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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub 

Do you have a question? Send it now...

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)

What do the new NICE guidelines tell us about the changing relationship between diabetes, kidney disease and cardiovascular health? 

The updated NICE guidance on type 2 diabetes marks an important change in how clinicians should think about diabetes, kidney disease and cardiovascular risk. In this episode of For Kidneys Sake, Prof Jeremy Levy and Dr Andrew Frankel explore why type 2 diabetes is increasingly being approached as a cardiorenal metabolic condition rather than simply a disorder of blood glucose. They discuss the growing importance of SGLT2 inhibitors as foundational therapy and why their kidney and cardiovascular benefits remain relevant even when their glucose-lowering effects diminish as kidney function declines.

Jeremy and Andrew also examine how diabetes treatment needs to adapt at different levels of kidney function, covering metformin, DPP-4 inhibitors, insulin and GLP-1 receptor agonists. They discuss when metformin should be withdrawn, why insulin requirements can change in advanced CKD, and the stronger role of GLP-1 receptor agonists for people with established cardiovascular disease. It’s a practical discussion of what the new NICE guidance means for clinicians managing the increasingly interconnected challenges of diabetes, CKD and cardiovascular disease.

Key Takeaways

• Type 2 diabetes is being reframed as a cardiorenal metabolic condition, with treatment considered alongside CKD, cardiovascular disease, heart failure and obesity. 
• SGLT2 inhibitors are now foundational therapy across multiple patient groups because of their cardiovascular and kidney benefits, rather than simply their glucose-lowering effect. 
• Kidney function increasingly determines diabetes treatment. As GFR declines, clinicians need to reconsider options including metformin, DPP-4 inhibitors and insulin. 
• Insulin requirements may fall in advanced CKD. The speakers explain that many patients may require a dose reduction as GFR falls below 20, although this needs individual adjustment. 
• GLP-1 receptor agonists have an increasingly important role, particularly for people with type 2 diabetes and established atherosclerotic cardiovascular disease.

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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub 

Do you have a question? Send it now...

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)

Could your patient's kidneys be telling you something their blood pressure isn't?

In this episode of For Kidney's Sake, Prof Jeremy Levy and Dr Andrew Frankel are joined by Prof Ian Wilkinson, President of the British and Irish Hypertension Society, to explore the close relationship between hypertension and chronic kidney disease (CKD). The discussion explains how the two conditions influence each other, why kidney assessment should form part of every hypertension diagnosis, and how clinicians can identify patients who may have secondary causes of hypertension or early kidney damage. The conversation focuses on practical steps for primary care, including the importance of measuring eGFR, urine ACR and performing urine dipstick testing as part of routine assessment.

The episode also examines treatment strategies that not only lower blood pressure but protect kidney function. The speakers discuss the role of ACE inhibitors and ARBs as kidney-protective therapies, the appropriate use of thiazide diuretics in CKD, selecting suitable second-line antihypertensive agents, blood pressure targets, monitoring schedules, accurate blood pressure measurement and lifestyle interventions. Throughout, the emphasis remains on treating the whole patient rather than simply targeting a blood pressure number, with practical advice aimed at improving long-term kidney and cardiovascular outcomes.

Top 5 Take aways: 

·  Hypertension and chronic kidney disease have a two-way relationship, each can contribute to the development and progression of the other. 

·  Every patient with hypertension should have kidney assessment including eGFR, urine ACR and urine dipstick testing. 

·  ACE inhibitors and ARBs are kidney-protective treatments and should be optimised where appropriate, even when blood pressure is already controlled. 

·  Thiazide diuretics remain effective in many patients with CKD and should not be avoided simply because kidney function is reduced. 

·  Accurate blood pressure measurement, lifestyle modification and good medication adherence are essential for protecting both cardiovascular and 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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub 

Do you have a question? Send it now...

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)

Many people still see finerenone as 'just another spironolactone ', but is that really the case? In this episode of For Kidney's Sake, Prof Jeremy Levy and Dr Andrew Frankel explore why finerenone is changing the management of diabetic kidney disease and where it fits alongside ACE inhibitors, ARBs and SGLT2 inhibitors.

The discussion covers the evidence behind finerenone, why patients remain at 'residual risk' despite current therapies, and how adding another treatment can further slow the progression of chronic kidney disease while reducing cardiovascular events. Jeremy and Andrew also share practical guidance on prescribing, monitoring potassium safely and overcoming the therapeutic inertia that can prevent patients from receiving effective treatments.

5 Key Takeaways

• Finerenone is not simply another spironolactone. Its selective mechanism and clinical trial evidence make it a distinct treatment for people with diabetic kidney disease.
• Many patients still have 'residual risk'. Even with ACE inhibitors, ARBs and SGLT2 inhibitors, ongoing albuminuria can signal continued kidney disease progression.
• Combination therapy matters. Adding finerenone to existing evidence-based treatments can further reduce the risk of kidney failure and cardiovascular events.
• Hyperkalaemia shouldn't be a barrier. With appropriate patient selection and routine monitoring, finerenone is straightforward to prescribe and generally well tolerated.
• Early optimisation is key. Identifying eligible patients during annual diabetes and CKD reviews gives clinicians the opportunity to protect kidney function before irreversible decline occurs.

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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub 

Do you have a question? Send it now...

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)

Is Kidney Disease Hiding in the Family?

Could a patient’s kidney disease have a genetic cause and what clues might we be missing? 

Genetic kidney conditions are more common than many clinicians realise, and spotting the signs early can change not only one patient’s care, but potentially the care of an entire family.

In this episode, Andrew and Jeremy are joined by renal genetics expert Dr Mel Chan to unpack the key genetic kidney conditions clinicians need on their radar. From polycystic kidney disease and Alport syndrome to congenital abnormalities and inherited kidney stones, they explore the red flags that should make you think genetics and why asking the right questions, making an early referral and securing a diagnosis can have a lasting impact on treatment, prognosis and family screening.

Key Takeaways:

1. Think family. Kidney disease, haematuria, stones, dialysis, transplantation or early deaths in relatives could be an important clue.
2. Spot the red flags. Young age, unexplained CKD, early hypertension, hearing loss, recurrent stones or congenital abnormalities should make you think genetic.
3. Suspect it? Refer it. You don’t need to be a genetics expert, recognising when specialist assessment is needed is what matters.
4. A diagnosis can change the story. Genetic testing can sharpen prognosis, guide treatment and help identify relatives who may also be at risk.
5. Keep patients on the radar. Childhood kidney problems don’t necessarily stay in childhood. Long-term follow-up can help prevent patients from returning years later with advanced CKD.

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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub 

Do you have a question? Send it now...

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)

This week on For Kidneys Sake, Prof Jeremy Levy and Dr Andrew Frankel celebrate an unlikely centenary: 100 years since creatinine was first recognised as a marker of kidney function. From the early days of serum creatinine and the Cockcroft-Gault formula to today’s eGFR reporting, the duo unpack how kidney function testing evolved and why the numbers we rely on still come with important caveats. 

The conversation explores why muscle mass can dramatically distort creatinine-based kidney estimates, when cystatin C offers a better alternative, and why gold-standard nuclear medicine tests remain impractical for routine care. 

Along the way, they tackle common misconceptions around eGFR, explain why urine ACR tells a different story entirely, and remind listeners that numbers should never replace clinical judgement. A witty, practical, and surprisingly celebratory deep dive into the science behind every kidney health check. 

Top 5 Takeaways

1. Creatinine has been used for 100 years — Serum creatinine was recognised as a marker of kidney function in 1926, making 2026 the centenary year of one of medicine’s most widely used blood tests. 

2. eGFR is helpful — but imperfect — eGFR improves on creatinine alone by incorporating age and sex into mathematical formulas, but it still struggles in people with unusually high or low muscle mass. 

3. Muscle mass matters more than many realise — A muscular person may appear to have “worse kidneys” on paper, while frail patients with low muscle mass can have deceptively normal creatinine levels despite significant kidney disease. 

4. Cystatin C is an underused alternative — Unlike creatinine, cystatin C is not heavily influenced by muscle mass and can provide a more accurate estimate of kidney function in selected patients. 

5. Kidney health is more than eGFR — Urine ACR measures kidney damage rather than filtration and can be abnormal even when kidney function appears normal. Both tests matter.

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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub 

Do you have a question? Send it now...

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)

How confident are you that the patient in front of you really has a urinary tract infection?

In this episode of For Kidneys Sake, consultant nephrologists Jeremy Levy and Andrew Frankel tackle one of the most common yet surprisingly complex conditions seen in primary care: urinary tract infections (UTIs). They explore why diagnosing a UTI is often less straightforward than it appears, emphasising the importance of symptoms over urine dipsticks and cultures alone. The discussion highlights the risks of overdiagnosis, particularly in older adults and those with asymptomatic bacteriuria, and explains when urine cultures can add value to clinical decision-making. 

The conversation also focuses on practical treatment strategies, especially for patients with chronic kidney disease. Jeremy and Andrew discuss antibiotic selection, the limitations of commonly used treatments such as nitrofurantoin and trimethoprim in CKD, and how to approach recurrent or complicated infections. They share evidence-based prevention strategies, review red-flag symptoms that require urgent assessment, and look ahead to emerging options such as vaccines for recurrent UTIs. 

5 Key Takeaways

• Diagnose UTIs primarily through symptoms, using urine tests to support rather than drive decision-making. 
• Avoid treating asymptomatic bacteriuria except in specific circumstances such as pregnancy. 
• Consider kidney function when selecting antibiotics, as some commonly used agents may be ineffective or harmful in CKD. 
• Recurrent UTIs warrant further investigation, including imaging and preventive strategies. 
• Fever, systemic illness, or severe flank pain should raise concern for more serious infection and prompt urgent assessment. 

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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub 

Do you have a question? Send it now...

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 refreshed re-release episode, Professor Jeremy Levy and Dr Andrew Frankel revisit one of the most common and challenging areas in chronic kidney disease (CKD) management: medication reviews and safe prescribing. 

They discuss how to approach prescribing decisions as kidney function declines, including the practical use of eGFR over creatinine clearance, how to identify medications that need dose adjustment or review, and the importance of “Sick Day” guidance during intercurrent illness. The episode also tackles common misconceptions around so-called “nephrotoxic” drugs and explains why many beneficial medications can often be continued safely with careful monitoring.

The second half of the episode focuses on pain management in CKD — a topic that frequently causes uncertainty in primary care. Jeremy and Andrew outline which analgesics can be used safely, which should generally be avoided, and how to prescribe cautiously using the principle of “start low and go slow.” They cover the safe use of paracetamol, tramadol, oxycodone, fentanyl and neuropathic pain agents, while reinforcing why regular NSAIDs and morphine are usually poor choices in patients with impaired kidney function. A highly practical refresher packed with prescribing tips for clinicians managing CKD in everyday practice.

5 Key Takeaways

• Use eGFR pragmatically for prescribing decisions in CKD rather than worrying excessively about creatinine clearance calculations.
• Regular NSAID use should generally be avoided in CKD, although very short courses may be acceptable in selected patients.
• Metformin is usually safe down to an eGFR of 30, with dose reduction recommended below 45 and good Sick Day guidance essential.
• Safe analgesic options in CKD include paracetamol, low-dose tramadol, oxycodone and fentanyl — but morphine should usually be avoided.
• “Start low and go slow” is the key principle when prescribing many medications, especially analgesics, in people with CKD.

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.

You can also join the community by signing up to our newsletter here

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub