‍Case Summary: Dorothy is a 68-year-old woman who is unaware of her chronic kidney disease (CKD stage 3), which is stable and most likely due to long-standing hypertension and age. She is shocked and worried after getting a letter about her kidneys and fears dialysis. She is otherwise well with no symptoms or relevant family history. The aim is to confirm the diagnosis, assess causes and modifiable risk factors, and reassure the patient.

Time efficient data gathering

Open questions are essential at the start to allow Dorothy to share her understanding and concerns about the letter. It is important to listen and without interruption, acknowledging the concerns as they are raised so that Dorothy feels reassured her concerns have been heard. It is important for the doctor to check the letter content information corresponds with the kidney results on file. Efficient data gathering involves clarifying what she knows, how she feels, and then checking for any red flag or overlooked symptoms of kidney disease or secondary causes. For example:

"I can understand why you would be worried about an unexpected letter, and I'm sorry it upset you. Can you tell me a bit more about the letter and how you have been feeling and then perhaps I can help explain why it was sent?'

Examples of targeted questions:

"Have you noticed any changes such as swelling, tiredness, or problems passing urine?"
"Do you have any family history of kidney problems, diabetes, or autoimmune conditions?"

Explore medication causes of renal impairment, and explore lifestyle briefly:

"Can you tell me about the medicines you take and if you’re taking anything else, including over-the-counter?"

Link: NICE CKD CKS

Language

Connect by using clear, simple language. Avoid jargon. Recognise that “CKD” and “kidney disease” can sound frightening. For example:

"Your kidneys are working less well than when you were younger, but they are still working well. If they keep working at this level they won't cause you a problem. The reason for the slight worsening is most commonly age and high blood pressure."

Use analogies if helpful:

"Think of your kidneys as filters that, over time, may not work quite as efficiently, a bit like how our eyesight or hearing change with age."

Reference: MRCGP annual reports and research

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Cues

Recognise Dorothy's verbal and non-verbal cues: she is shocked and anxious about the letter and mentions a friend who needed dialysis. Respond with empathy, for example:

"I can see this was a real shock for you, and I understand why you might be worried after seeing what your friend went through."

When she asks, "Will I need dialysis?", pause and address this specifically.

Goals

Set explicit consultation goals together. Early on in management, involve her:

"By the end of our conversation, would it be helpful if I could explain what your kidneys are doing now, what this means for your health, and what we can do to keep you well?"

Flow

Keep Dorothy on board with a logical progression through your conversation. Start with Dorothy's story, check for symptoms, review medication and risk factors, then explain the results and diagnosis before moving to management. It helps to acknowledge her replies in transitions:

"Thank you for sharing that. Let’s look together at your recent test results and I’ll explain what they mean."

Differential

Generate an appropriate differential based on likelihood:

• 1. CKD stage 3 secondary to hypertension and age (most likely in a 68-year-old with a history of hypertension and gradual decline in eGFR)
• 2. CKD from other vascular causes (e.g. atherosclerosis)
• 3. Unrecognised diabetic nephropathy (if undiagnosed diabetes)
• 4. Glomerulonephritis or other primary renal disease (less likely given lack of urinary symptoms or family history)
• 5. Drug-induced nephropathy (if she had been exposed to nephrotoxic drugs)
• 6. Obstructive uropathy (much less likely in absence of urinary symptoms)

Reference: NICE NG203: CKD

Impact

Understand the impact on Dorothy’s psychological wellbeing (shock, anxiety about dialysis, past bereavement, living alone). Ask:

"How has receiving this letter affected you day-to-day?"

Ask about daily activities, support, and coping to tailor advice and follow-up. Don’t forget the social context: living alone and needing reassurance.

Conciseness

Explanations should be brief and clear, avoiding jargon. For example, instead of "Your eGFR has been persistently 52ml/min for over 3 months, indicating stage 3 CKD," you might say:

"Your blood tests show your kidneys are working a bit less well than they used to, but this has been steady for some time. This is called stage 3 CKD and is very common as people get older, especially with high blood pressure. Most people with stage 3 CKD do not progress to more serious kidney problems"

Sharing

Share your reasoning and explain next steps:

"The most likely reason your kidneys are not working as well is your blood pressure over the years. The good news is it’s stable and there are things we can do together to protect your kidneys."

Verbalise your process:

"We send urine tests to check for any extra signs of kidney stress or hidden damage, so we don’t miss anything."

Reference: Consulting in a nutshell, Roger Neighbour

Options

Provide a menu of evidence-based options, discussing pros and cons and addressing Dorothy's expects and concerns around dialysis.

1. Continued monitoring of kidney function with annual blood and urine tests (uACR, eGFR, creatinine).
2. Regular blood pressure monitoring and control (target ≤140/90 or as per comorbidities).
3. Reviewing medication for nephrotoxicity (avoid NSAIDs, careful with ACE inhibitors but continue unless contraindications).
4. Lifestyle optimisation: maintaining healthy weight, exercise as tolerated, low salt intake, adequate hydration, not over-restricting protein or fluids without dietitian advice.
5. Vaccinations (annual flu, pneumococcal, COVID-19) to reduce infection risk.
6. Information on recognising symptoms that would require prompt review (e.g., swelling, breathlessness, change in urine, confusion, persistent vomiting).
7. Addressing psychosocial factors: offering access to support for emotional well-being, signposting to kidney charities if wanted.
8. If persistent proteinuria, declining eGFR, or unclear cause, consider referral to nephrology—explain current need is low given stability.

Reference: NICE CKD Guideline

Understanding

Encourage engagement and check Dorothy’s understanding  using open prompts:

"I’ve given you a lot of information. What questions do you have?"

Expecting questions gives permission for patients to ask, and encourages patient engagement.

RCGP examiner feedback. N.Turner.

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Bespoke solutions

Offer solutions matched to Dorothy’s health, ideas, and circumstances. Example:

" keeping active and making sure your blood pressure is controlled are some of the best ways to protect your kidneys. As you live alone, if you ever worried please contact us, particularly if you notice swelling, tiredness, or problems with your urine.

We will do some routine kidney tests every year to keep an eye on things together. If you’d like, I can connect you with a kidney charity for more support or information."

Adjust follow-up, management, and explanation depending on what matters to her (e.g., maintaining independence, fears about dialysis, support with healthy living).

Reference: MRCGP annual reports and research

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Trusted Resources for Further Reading

• NICE CKD Clinical Knowledge Summary
• NICE Guideline NG203: CKD
• BNF guidance for drug dosing in CKD
• Kidney Care UK – Living with Kidney Disease

Summary for Candidates: In this case, you are rewarded for a structured, patient-centred approach that starts with Dorothy’s agenda, provides simple and empathic explanations, targets reversible factors, advises evidence-based management, and checks understanding. It is important to acknowledge and address her psychological distress, correct misconceptions about dialysis, and provide reassurance about the problem and its common nature. Positively frame her situation and the many options she has to keep well.

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