Section 5: Configuration of healthcare to manage CKD

The Renal NSF: Part 1 Standard 1: Patient centred service Standard 2: Preparation and choice Standard 3: Elective Dialysis access surgery Standard 4: Dialysis Standard 5: Transplantation

The Renal NSF: Part 2 Quality requirement 1: Prevention and early detection of chronic kidney disease (CKD) Quality requirement 2: Minimising the progression and consequences of CKD Quality requirement 3: Acute renal failure Quality requirement 4:End of life care

Management of CKD Early Detection of CKD Early Detection of CKD Think/Report eGFR Early Detection of CKD Early Detection of CKD Delay progression & reduce CVS Risk Prevent uraemic complications Modify co morbidities Prepare for RRT ACE inhibitors Malnutrition Cardiac disease Education BP control Anaemia Vascular disease Informed choice of RRT/conservative management Glucose control Calcium Phosphate PTH Drug interactions Timely access placement/ Transplant Listing Smoking cessation Acidosis Neuropathy/ Retinopathy Timely initiation of RRT Detection – reporting in eGFR – pilots in the UK show success and support new models of care Delay progression = cardiovascular risk reduction Cardiovascular risk is the major risk in all patients with CKD Normal cardiovascular risk factors such as inflamation, malnutrition and calcium phosphate abnormalities aggravate the traditional cardiovascular risk factors Anxiety about CKD often leads to failure to prescribe or inadequate doses of certain drugs CKD involves a classic risk state to a classis long term conditions state – education, empowerment, risk reduction, case management MB medicines management Each cell is straightforward, the cells interact CKD = chronic kidney disease; RRT = renal replacement therapy

NEOERICA: percentage recording of creatinine and prevalence of Stage 3–5 CKD by age Patients (%) 80 Recorded serum creatinine Stage 3–5 CKD 70 60 50 40 Figure 2 from draft of primary nephrology paper (May 2005) 30 20 10 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+ Age groups

Source of Late Referrals Lamiere - NDT 1999

DIABETOLOGISTS NEPHROLOGISTS CARDIOLOGISTS GEN. PRACTICE GEN. MEDICINE SILO MANAGEMENT NEPHROLOGISTS DIABETOLOGISTS GEN. PRACTICE CARDIOLOGISTS GEN. MEDICINE

INTEGRATED MANAGEMENT CHRONIC DISEASE MANAGEMENT SILO MANAGEMENT INTEGRATED MANAGEMENT CHRONIC DISEASE MANAGEMENT DIABETOLOGISTS GEN. PRACTICE CARDIOLOGISTS GEN. MEDICINE

CKD: An Overall Health Approach Complications Normal Increased risk Damage GFR Kidney failure DEATH Screening for CKD risk factors CKD risk factor reduction, screening for CKD Diagnosis and treatment, treat comorbid conditions, slow progression Estimate progression, treat complications, prepare for replacement Replacement by dialysis and transplant

Cardiac Kidney Diabetes Anti coagulation Anti arrhythmics Medical treatment of CHF CKD Stage 4 Anaemia Acidosis Bone disease Preparation/choice CKD Stage 1, 2,3 Education Blood pressure Smoking cessation Lipid control Medicines Management Diet advice Exercise Psychosocial support Glycaemic control + DM + CHD Complications eyes feet kidney CKD Stage 5 RRT PD HP Tp Radiology Surgical interventions

QOF indicators for CKD 2009 6 40-90% 11 40-70% 4 40-80% Register of patients over 18 with CKD 3-5 6 Percentage of patients on the CKD register whose notes have a record of BP reading in last 15 months 40-90% Percentage of patients on the CKD register in whom the last BP reading, measured in the last 15 months was 140/85 or less 11 40-70% Percentage of patients on the register with hypertension and proteinuria treated with an ACE-I or ARB (unless side-effects are recorded) 4 40-80% Percentage of patients on the register whose notes have a record of urine ACR or PCR in the previous 15 months