Detecting chronic kidney disease (CKD) early can provide opportunities to optimise native kidney function, prevent further decline and plan for timely kidney transplantation if required. Understanding how children are found to have kidney disease and present to specialist kidney care may help tailor interventions to support a timelier diagnosis. The aim of this study was to examine the pathway to specialist care for UK children who present late to nephrology with advanced CKD (requiring kidney replacement therapy within 90 days of first nephrology review) to determine whether there are modifiable aspects to presentation and diagnosis.

Semi-structured, in-depth qualitative study. A topic guide based on the theoretical framework of health behaviour by Scott et al, The Model of Pathways to Treatment, was developed to capture differences in symptom appraisal and help-seeking before reaching nephrology care.

UK paediatric nephrology units (n=4) between December 2017 and December 2020.

Children and young people who experienced a late presentation of CKD and their parents/carers.

Twenty-two participants participated across 19 interviews: seven children (two male, median age 16, IQR 13–17.5 years) and 15 parents. A typology of presentation to healthcare was identified: commonly, families reported repeated cycles of primary care help-seeking before onward referral to specialist care, although long appraisal intervals were also noted. In all cases, secondary care referral led to onward nephrology care involvement. Narratives highlighted that not all cases of late presentation could be avoided.

A typology of symptom appraisal and help-seeking can inform interventions to improve CKD detection. Interventions that support symptom appraisal and consideration of targeted CKD testing in children may help reduce appraisal and help-seeking intervals, respectively.

To understand why patients with chronic kidney disease (CKD) may not be treated according to international guidelines for myocardial infarction (MI).

Multicentre qualitative interview study. Interviews were analysed using reflexive thematic analysis approach as outlined by Braun and Clarke to generate themes associated with MI treatment decision-making for, and by, patients with CKD.

Four National Health Service hospital centres in the UK (February 2022 to July 2024).

A purposive sample of 46 participants (patients and clinicians). Clinicians (n=32) were senior doctors-in-training or consultants in cardiology, nephrology, acute or emergency care or cardiac surgery. Patient participants (n=14) had CKD, defined as an estimated glomerular filtration rate 2, or receipt of kidney replacement therapy (KRT).

Despite expressing strong views regarding their health priorities, patients reported minimal involvement in treatment decision-making. Decision-making by clinicians was driven by the desire to avoid causing harm to patients by ‘active’ treatment initiation. In general, despite the concept of evidence-based medicine being widely accepted, there remained scepticism of guidelines or epidemiological data, especially in the light of personal adverse experiences or anecdotes. Clinicians described how, in the absence of collaborative decision-making and a clinical safety-net for managing treatment complications, they tended to make conservative treatment decisions for patients with CKD.

Interventions to foster teamworking between specialists and ensure adequately resourced specialist clinical service safety-nets may improve access to treatments for MI for people with CKD. Intervention development and evaluation should follow to determine if outcomes for people with CKD and MI can be improved.