1. 18 week commissioning pathways for kidney disease and renal transplantation Specialty Clinical Leads Lawrence Goldberg: CKD and ESRF pathways John Scoble: Live donor pathway

2. Reasons for a CKD 18 week commissioning pathway High prevalence of CKD  8.5% of population Continuing increase in ESRF population  7.6% increase 2005-2006 (Renal Registry) Potential benefits of evidenced based interventions  Reducing cardiovascular morbidity  Reducing progression of renal disease  Better management of CKD complications  Better preparation for renal failure Potential benefits of more systematised, stream-lined care

3. CKD pathways overview Pathway 1: General nephrology/primary-secondary care interface Pathway 2: Management of patients approaching or at end stage renal failure Haemodialysis Peritoneal dialysis Transplantation (live or deceased donor) Active medical non-dialysis management/maximum conservative care

4. Pathway Development process 1 st draft Lawrence Goldberg, specialty lead Kathryn Griffith, GP lead Steve Laitner, GP, PH Consultant, DH 18 week team 2 nd draft Donal O’Donoghue Paul Stevens John Scoble Louise Wells (renal dietician) Rob Lusuardi (specialist commissioner) Juliette Kingcombe (DH Renal Team Lead) Consensus meeting 25.2.08

5. Principles behind CKD clinical pathway development Consistency with emerging NICE CKD guidelines Draft guidelines to be published 11 th March 2008 Consistency with other guidelines where appropriate Renal Association/RCP Haematuria (parallel 18 week pathway, RA/BAUS draft consensus) Type 2 diabetes NICE CVD risk assessment ‘Best practice’

6. CKD 18 week pathway overview

7. Nephrological ‘highlights’ Urinary albumin:creatinine testing for all eGFR<60 (no routine dipstick) Threshold for lower BP target/ACEI 30mg/mmol (≈0.5g/24hr) BP targets: 120-140/70-90 no proteinuria 120-130/70-80 proteinuria ≥0.5g/day Hb testing for GFR <45 Ca/PO4/PTH testing for GFR <30

8. Referral criteria Patients without diabetes eGFR<30 GFR decline >=5ml/min within 1yr or >=10ml/min within 5 yrs Proteinuria >1.0g/day (ACR>70) Haematuria with proteinuria >0.5g/day (ACR>30) Patients with diabetes eGFR<30ml/min GFR decline >=5ml/min within 1yr or >=10ml/min within 5 yrs IF NO SIGNIFICANT ALBUMINURIA All patients Nephrotic syndrome Management of CKD-associated anaemia Management of disorders of bone metabolism (Ca/PO4/PTH) CKD with uncontrolled hypertension on 4 agents Suspected renal artery stenosis

9. 18 week clocks for early CKD/general nephrology Start: on referral for specialist care Clock continues to run: Awaiting further investigations (pathology, radiology) Renal biopsy Stop: Medical treatment administered/active monitoring. Provision of care plan to patient Renal artery angioplasty/stent Referred to other renal unit for further investigation/treatment Discharged back to referrer

10. 18 week clocks for CKD stage 5 management Clock starts when referred for preparation for ESRF treatments (follows patient education/information/discussions) Clock startsClock stops Patient wants HD, and referred for vascular access work-up Time of definitive access surgery (AVF/graft) Patient wants PD, and referred for PD catheter work-up Time of insertion of PD catheter Patient wants a kidney transplant, and transplant work-up begins Time when entered on to national waiting list (or when considered unsuitable) Patient wants live donor transplant, and transplant work-up begins Live donor surgery takes place, or donor unsuitable Patient wants active medical (non- dialysis) management only Care plan agreed with patient