1. Section 5: Configuration of healthcare to manage CKD

2. 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

3. 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

4. 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

5. 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

6. Source of Late Referrals Lamiere - NDT 1999

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

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

9. 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

10. 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

11. 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